Linguistic diversity in the United States continues to impact the way in which speech-language pathologists (SLPs) and audiologists conduct their day-to-day work. According to a 2016 American Community Survey on language use in the United States, more than 65 million people use a language other than English and more than 1,000 different languages are spoken (Gambino, 2016). The number of languages used and the number of individuals who require services in a language other than spoken English far exceed the capacity of bilingual service providers to accommodate them. Therefore, it may be necessary for the clinician to collaborate with an interpreter, transliterator, or translator to ensure clinically appropriate services. Furthermore, legal and ethical standards (American Speech-Language-Hearing Association [ASHA], 2017; Civil Rights Act of 1964, as amended; Executive Order No. 13,166 [2000]; Individuals with Disabilities Education Act of 1990, as amended) require that services to individuals who use a language other than spoken English must be delivered in the language most appropriate to that student, client, patient, or family.

When collaborating with interpreters, transliterators, or translators, a clinician remains responsible for planning the session, selecting culturally relevant materials, and appropriately administering the services. It is the legal and ethical responsibility of the facility and its providers to offer reasonable and appropriate accommodations to facilitate access to clinical services.

Definitions

Interpreter—a person trained to convey spoken or signed communications from one language to another. Interpretation services may be provided

• in person;
• by phone, such as language lines for interpreting spoken languages (e.g., French to English);
• using videoconferencing services/video interpreting platforms; and/or
• using apps available via electronic devices, such as tablets, computers, and smartphones.

Clinicians are responsible for considering the goals of the session, discussing the client's/family's needs, evaluating the benefits of service in all language(s) necessary to facilitate the sessions goals, and determining the optimal interpreter to assist in the provision of services (Langdon & Saenz, 2016).

Transliterator—a person trained to facilitate communication for individuals from one form to another form of the same language. This person is most often used for individuals who are d/Deaf or hard of hearing (D/HOH) who use oral, cued, or manual communication systems rather than a formal sign language. Transliterators differ from interpreters in that interpreters generally receive information in one language and interpret the information in a different language.

Translator—a person trained to translate written text from one language to another.

Role of Cultural and Linguistic Brokers

Interpreters, transliterators, and translators may serve in the role of a cultural broker (Torres, Lee, & Tran, 2015) or a linguistic broker (Orellana, Martínez, & Martínez, 2014).

Cultural Broker—a person knowledgeable about the client's/patient's culture and/or speech-language community. The broker passes cultural/community-related information between the client and the clinician in order to optimize services.

Linguistic Broker—a person knowledgeable about the client's/patient's speech community or communication environment who can provide valuable information about language and sociolinguistic norms in the client's/patient's speech community and communication environment.

An informant or broker can provide

• grammaticality judgments, indicating whether the client's/patient's language and phonetic production are consistent with the norms of that speech community or communication environment;
• information on the language socialization patterns (i.e., use of language in socially appropriate ways based on the culture) of that speech community or communication environment; and
• information on other areas of language, including semantics and pragmatics.

Roles and Responsibilities of Audiologists and SLPs

When collaborating with interpreters, transliterators, or translators, audiologists and SLPs remain responsible for planning the session, selecting culturally relevant materials, and appropriately administering assessment and treatment. Although the list below outlines ideal characteristics, sometimes it is not always possible to find an interpreter meeting all of these criteria in a timely manner. The interpreter or transliterator assists the clinician in gathering the appropriate data and provides language support for services appropriate to the client.

Appropriate roles and responsibilities of audiologists and SLPs when collaborating with an interpreter, transliterator, or translator include the following:

• Identifying clinical exchanges for which collaborating with an interpreter, transliterator, or translator is necessary.
• Identifying the appropriate language(s) of service for clients/patients/families, including identifying the preferred language for meetings, services, and written documentation.
• Advocating for access to an interpreter, transliterator, or translator.
• Making advance arrangements to ensure appropriate physical accommodations (e.g., space, lighting, noise) necessary for successful collaboration, including placement of phone, computer, and/or video screen to ensure visibility and audibility during remote sessions.
• Creating a foundation for successful collaboration, including
• scheduling additional time in sessions to accomplish goals;
• verifying the cultural appropriateness of assessment and treatment materials and reviewing potential bias;
• reviewing prompts in assessment materials for linguistic influences of a second language and consulting with additional experts and resources to review phonetic information and potential syntactic influences;
• arranging for documents written in unfamiliar languages to be translated, to ensure that they, as clinicians, are aware of the content of the documents; and
• understanding that the translation of written material from English to a non-English language may alter the intent and overall readability of the document.
• Understanding that not all spoken and manually coded languages, including American Sign Language (ASL), have a written form.
• Seeking an interpreter, transliterator, or translator who has knowledge and skills that include
• having native or near-native proficiency in the appropriate language(s), dialect(s), and communication system(s)—and the ability to provide accurate interpretations, translations, and transliterations;
• understanding the client's/patient's/family's particular culture and speech community or communicative environment;
• understanding the basic principles of assessment and/or intervention and having the ability to provide context to the client/family to understand clinical objectives and professional terminology;
• understanding professional ethics, client–patient confidentiality, and the need to limit bias; and
• understanding that each country has its own sign language and that dialectal differences exist in sign languages.
• Establishing collaborative relationships with interpreters, transliterators, and translators to maximize the effectiveness of services.
• Maintaining appropriate professional relationships among the clinician, the client/patient/family, and the interpreter, transliterator, or translator (ASHA, 2016).
• Seeking information on the features and developmental characteristics, when available, of the language(s) and/or dialect(s) that are spoken or signed by the client/patient/family.
• Obtaining information on the client's/patient's/family's significant cultural and linguistic influences, when possible.
• Understanding the standardization process for assessments and how collaboration with an interpreter, transliterator, or translator may influence or possibly invalidate standard scores.
• Educating the interpreter, transliterator, or translator regarding the goals and intent of the session.

It may be difficult for a clinician unfamiliar with the language to judge the quality of interpreting, transliteration, or translation services. Clinicians must do their best to ensure that services provided are reliable and must make every effort to become familiar with their clients' languages (e.g., language structures, phonemic inventory, how translation/interpretation may impact the message, etc.). ASHA's (2016) Code of Ethics (Principle I, Rules A and B; Principle II) provides the baseline for the quality of services that the clinician is expected to provide. Clinicians must provide all services competently, which indicates using the best resources available under the circumstances.

Selecting an Interpreter, Transliterator, or Translator

Factors included in the selection of an interpreter, transliterator, or translator include the individual's

• level of proficiency in spoken English and in the language or dialect used by the client/patient/family;
• prior experience;
• educational background and/or professional training; and
• status of certification and/or licensure.

Requirements for education, training, certification, and/or licensure of interpreters, transliterators, and translators vary by state and employer. Some state laws and regulations impose additional standards and requirements for working in specialized settings (e.g., legal, medical, and educational), particularly when serving individuals who are D/HOH. See State-by-State Regulations for Interpreters and Transliterators and Interpreter Licensure by State for requirements for interpreters and transliterators for individuals who are D/HOH.

Employers such as school districts, courts, and health care systems may also have interpreting aptitude tests, performance assessments, or boards that evaluate interpreters before they can be hired. Additionally, these employers may require credentialing from a state or national organization. A growing number of state and national associations have professional standards and certification for trained interpreters (e.g., International Medical Interpreters Association, Registry of Interpreters for the Deaf). Trained and/or certified professionals have codes of ethics within their professions that they are expected to maintain. See the Registry of Interpreters for the Deaf, National Council for Interpreters in Health Care, and America TA.

Most of the time, the administration and/or the clinician's facility will provide the name of an individual who will serve as interpreter, transliterator, or translator. A clinician may or may not have the opportunity to provide input on the selection for the initial meeting with the client/patient/caregiver. However, to the maximum extent possible, employers are encouraged to use the same interpreter, transliterator, or translator for multiple assignments, so that the clinician may establish a familiar relationship and provide knowledge of the work process.

Individuals who serve as interpreters, transliterators, or translators include

• professionals with specific training in this area;
• bilingual assistants;
• bilingual professional staff from a health or education discipline other than communication disorders; and
• bilingual staff available within the facility but outside of health or education disciplines.

This list, arranged in approximate order of preference, does not account for the unique variables inherent in clinical interactions.

Bilingual assistants and professional staff must consider their linguistic proficiency in both languages being used, including their proficiency in the local dialect of the language(s) being used by the client/patient/family and their own knowledge and skills for interpreting, transliterating, and translating. Dialectal mismatches—such as a Spanish-speaking individual from Mexico interpreting for a Spanish-speaking client from Spain or Argentina—may result in inaccurate interpretations, translations, and/or cultural misunderstandings (Ostergren, 2014).

Family Members or Friends Serving as Interpreters, Transliterators, Translators

On limited occasions, there may be reasons why a family member or friend serves as an interpreter, transliterator, or translator—either due to client preference or because all other efforts to locate an appropriate interpreter, transliterator, or translator have been exhausted. In addition, a facility may be unable to locate an individual who is able to meet the individual linguistic needs of the client. For example, family members may be the only source of information regarding speech patterns prior to a brain injury in a multilingual individual.

Family or friends acting as interpreters, transliterators, or translators may present potential conflicts. The reliability of the interpretation, transliteration, and/or translation may be compromised given the potential conflict of interest and likely limited training of the family member or friend. It is important to be mindful of risks in high-stakes situations, such as mediation, evaluations, or situations where cognitive capacity might be in question. Children may not possess the emotional maturity and sensitivity necessary to serve in the role to assist family members in the provision of services.

When using family members or friends in this role, the clinician considers the following factors:

• Intent of the message (e.g., sharing a diagnosis of a cognitive-communication deficit, which may be met with resistance or a strong emotional response vs. providing safe swallowing techniques).
• Age of the family member providing interpretation, the position and role of that individual within the family structure, and their overall linguistic ability.
• The qualification of interpreters to provide services, be it in a school or a health care setting.

Title VI of the Civil Rights Act of 1964 and the Equal Educational Opportunities Act of 1974, public schools must ensure that English learner (EL) students can participate meaningfully and equally in educational programs. Joint guidance from the U.S. Department of Education (ED) and the U.S. Department of Justice (DOJ) reminds state education agencies (SEAs), public school districts, and public schools of their legal obligation to ensure that EL students can participate meaningfully and equally in educational programs (U.S. Department of Justice & U.S. Department of Education, n.d.)

According to the civil rights provision of the Patient Protection and Affordable Care Act (2013), Section 1557 expands on existing policies that prohibit discrimination based on race, color, national origin, sex, age, or disability. Health care providers who receive federal money from the U.S. Department of Health and Human Services must take reasonable steps to offer free, timely oral interpretation services to people with limited English proficiency. Providers must also provide free and timely aids and services (including sign language interpreters) for people with disabilities, and they must provide language assistance (including translation of documents). Providers cannot require clients to provide their own interpreters and may not rely on an adult accompanying the patient to interpret, except in an emergency or if the client specifically requests that the accompanying adult interpret or facilitate communication. Clients can decline the services of an interpreter.

Collaborating With the Interpreter or Transliterator

Successful collaboration is inherent to successful service delivery and is based on a shared understanding of the goals established by the clinician. This can be achieved by properly preparing the interpreter or transliterator for what to expect from the assessment or treatment session. Always keep in mind that the audiologist or SLP is responsible for the session and should remain in the room during the entire session. After the assessment or treatment session, the clinician and the interpreter or transliterator should discuss how the session went to be sure that no issues arose that need to be discussed (Langdon, 2002).

Collaborating with an interpreter or transliterator may influence a clinician's ability to diagnose, treat, and seek reimbursement for services. Interpreters or transliterators may inadvertently misrepresent a meaning when converting messages into another language and/or reporting client responses, particularly if they are unaware of the purpose of the exercise or assessment. Interpreters and transliterators may also influence client/patient responses or understanding of clinician questions. In some cases, seemingly small errors can change the meaning of a question or response and can have drastic effects on outcomes. For this reason, it is best to work with a trained interpreter or transliterator when possible. A clinician will need to provide training prior to the session to ensure the best possible outcomes during clinical sessions and should periodically check in to assist in the effective delivery of services (Langdon & Saenz, 2016).

SIG 16's Perspectives article Working With Interpreters to Support Students Who Are English Language Learners provides great information for how to debrief with an interpreter before and after your session.

Prior to the Session

Actions taken prior to the session to ensure a successful collaboration include the following:

• Meeting in advance to allow adequate preparation time.
• Reviewing and learning greetings and the appropriate pronunciation of names in the family's primary language.
• Providing written information prior to the meeting, including proper names of those at the meeting, technical terms and abbreviations, copies of visual references, and topics to be covered.
• Establishing a rapport with the interpreter or transliterator.
• Discussing prompts or cues that the interpreter or transliterator can use if the clinician speaks too quickly or too softly or if the clinician's speech or meaning is unclear.
• Reviewing the goals and procedures of the session or clinical interaction, including discussing
• whether gestures may or may not be used;
• the possible influence of vocal intonation;
• the presence of feedback to the client/patient; and
• other cues that may inadvertently influence the session in unanticipated ways.
• Reviewing the impact of additional cuing and prompting through repetition of prompts in English by the clinician to target language.
• Explaining confidentiality policies pertaining to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations and the ASHA Code of Ethics (ASHA, 2016), and documenting that these policies have been explained and accepted.
• Reviewing assessment administration procedures or intervention techniques, and ensuring that the interpreter or transliterator is aware of (a) the purpose of such procedures/techniques and (b) the need to provide test stimuli—in the client's language—that are as close as possible to the English prompts to elicit the desired type of response.
• Providing, in advance, a copy of assessment prompts to be used to avoid any sight translations.
• Discussing the impact that fingerspelling may have on assessment results, and reviewing possible differences in the conceptual accuracy of some signs relative to spoken language.
• Reviewing procedures for capturing the client's verbal and behavioral responses.

During the Session

Actions taken during the session to ensure a successful collaboration include the following:

• Introducing the clinician and the interpreter or transliterator to the client in the client's native language.
• Describing the role of the clinician and the interpreter or transliterator, and clarifying expectations.
• Reviewing and discussing the process for data collection.
• Using short, concise sentences, and avoiding the use of idiomatic expressions, as these are not conveyed easily between languages.
• Pausing frequently to allow the interpreter or transliterator enough time to convey information accurately.
• Allowing enough time for the interpreter or transliterator to organize information, recognizing that variations in narrative discourse across languages will influence the amount of information required to accurately convey intent.
• Periodically checking with the interpreter or transliterator to see if the clinician's speech is too fast, too slow, too soft, or too unclear.
• Understanding that words that express feeling, attitude, and qualities may not have the same meaning when directly interpreted or translated.
• Talking directly to the client and ensuring comprehension of diagnosis, prognosis, and treatment recommendations, as the clinician would do with all clients.
• Being aware of nonverbal body language and gestures that may be offensive to the client's/family's culture.
• Observing nonlinguistic measures to supplement the interpreted or translated information.
• Avoiding oversimplification of diagnoses, recommendations, and other relevant information.
• Providing written materials in the client's/family's preferred written language.
• Scheduling extra time for the session and scheduling breaks, as appropriate.

After the Session

Actions taken following the session to ensure a successful collaboration include the following (Langdon & Saenz, 2016):

• Reviewing the client's responses, as well as the target responses, and determining if they may have been influenced by cultural and/or linguistic variables.
• Discussing any difficulties or concerns.

Working With Translators

Special considerations for effective collaboration with translators include

• providing written materials well in advance;
• being aware that some spoken languages do not have written forms;
• understanding that a client's/family's preferred written language may not be the same as the preferred spoken language; and
• allowing time for the translator to consult and ask questions, particularly as it pertains to medical terminology and recommendations.

Dialectal differences may influence translation. To the maximum extent feasible, ensure that documents are written in a way that is the most universally understood by speakers of different dialects of a written language.

All vital written documentation provided to the family should be translated into the client's/patient's/family's preferred language. Allow for sufficient time for the translator to work with the documents.

Provide all legal documents and highly relevant materials to the translator ahead of time. In a research setting, informed consent is presented to each human subject “in language understandable to the subject” (Federal Policy for the Protection of Human Subjects, 2001). Informed consent is documented in writing in most situations.

Paying for an Interpreter, Transliterator, or Translator

Funding for interpreters, transliterators, or translators may come from a variety of sources, as clients/patients are not expected to pay out of pocket for these services to ensure access to care.

For individuals who are D/HOH, the Americans with Disabilities Act of 1990, as amended, mandates that all public and private agencies that provide services to the general public, and all employers with 15 or more employees, must be accessible. Therefore, the agency, service, or business is responsible for payment for interpreting services. For students who are deaf and have an Individualized Education Program (IEP), educational interpreting is considered a Related Service under the Individuals with Disabilities Education Act of 2004 (IDEA). As with all IEP supports and services, there is no charge for Related Services. An educational interpreter or transliterator is a member of the IEP team for any student who is D/HOH receiving this service because educational interpreting and/or transliterating is considered a Related Service.

Title VI of the Civil Rights Act of 1964 mandates equal access to services regardless of language used. Executive Order 13,166 further stipulates that agencies receiving public funding, such as Medicaid/Medicare or IDEA funding, must provide and arrange for that access and are responsible for the funding of an interpreter, transliterator, or translator, as needed. Consideration is made for smaller agencies with lower annual operating budgets that may influence the agency's ability to provide access. See guidance provided by the U.S. Department of Health and Human Services.

At this time, third-party payers do not pay for the services of an interpreter. However, some third-party payers and insurers may require documentation for how the non-English language or communication system will be addressed prior to sending reimbursement.

Contracting

Clarify the party responsible for payment of interpreter, transliterator, or translator services when providing contracted services. For example, it may be determined that it is the facility's responsibility to provide appropriate accommodations for those services, or it may be decided that interpretation services should be listed as a line item in the services the clinician provides.

Service Provision

The client/patient/family should be consulted to determine the mode of communication or accommodation that is preferred and best suited to each clinical interaction. This choice may vary depending on the type of clinical encounter (i.e., meeting, counseling, assessment, intervention) and the needs of the setting. Consider that a client's equal access to services encompasses the continuum from making an appointment for services, to completing paperwork and case history forms, to participating in face-to-face meetings, to receiving written reports, as well as interaction during assessment and intervention.

During service provision, clinical encounters with the client and family may necessitate different types of interpreting, transliteration, and translation services.

Simultaneous Interpreting (SI)—the interpreter converts a speaker's or signer's message into another language while the speaker or signer continues to speak or sign. This approach may be used to keep meetings flowing without interruption in a clinical setting or when most persons at the table speak English. Simultaneous interpreting may be more commonly used with manually coded languages than with spoken languages due to the auditory interference that may be present in spoken language interpretations, if the interpreter is speaking at the same time as the clinician or the client/patient (Langdon & Saenz, 2016).

Consecutive Interpreting—the interpreter transmits the message after a section of the source language is produced and during a pause. The interpreted message is divided into segments of appropriate length in order to be conveyed to the target language and be well-understood. Compared with SI, consecutive interpreting may be more commonly used during assessment and intervention of spoken language. Additionally, interpreters of both spoken and manually coded languages may utilize consecutive interpretation when the client provides a great deal of information at once in order to fully comprehend the information and then accurately convey the meaning. Consecutive interpreting may also be preferred for clients/patients/families with compromised cognitive abilities (Langdon, 2002).

Effective interpreting may alternate between consecutive and simultaneous, depending on the needs of the clinical interaction and the communicative intent.

Oral Transliteration—the transliterator mouths words clearly so that people who are D/HOH and skilled in speech reading can understand what is being said by watching the transliterator's face, gestures, body language, and lips. Oral transliterators may choose to rephrase a message with words that are more visible on the lips when possible. They may also "voice" for individuals who are D/HOH (Registry of Interpreters for the Deaf, 2007).

Cued Speech Transliteration—the transliterator uses handshapes and movements in different locations near the mouth to depict sounds used in spoken language. Cued speech is generally used to support speech reading by providing a visual representation for the sounds in a language. However, it is not a form of sign language (National Cued Speech Association, 2006).

Sign Transliteration—the transliterator uses signs in the word order of the target spoken language (e.g., signed English) to convey the spoken message for people who are D/HOH who do not use a formal sign language (e.g., ASL).

Prepared Translation—the translator prepares the written version of a document, such as a letter or report, in advance. Enough time must be allowed on the basis of task complexity. A reminder-of-next-appointment letter will not take long. However, even a short assessment piece could take much longer, depending on the focus of the assessment. The clinician should be available to answer the translator's questions about the materials. Prepared translation may be the most common form of translation in clinical settings.

Prepared translation can be used to prepare instructions, assessment, treatment, and education materials in advance. In addition, prepared translation may be important when the clinician is providing written reports or documentation of assessments and progress, such as IEPs or discharge reports.

Sight Translation—the translator provides a spoken or signed translation while reading a written document in a clinical encounter reserved for more immediate and spontaneous needs. This approach is not a reasonable option for informed consent or other legal documents or for formal assessment measures. Sight translation may be used when the clinician decides that certain materials may be more appropriate to use in a clinical encounter than those which had been previously prepared (Langdon & Saenz, 2016).

Not all spoken and manually coded languages, including ASL, have a written form.

Technology

Technology offers opportunities for individuals to access interpretation, transliteration, and translation services.

• Telephone or video relay/video remote interpreting services offer access to off-site interpreters or transliterators. Clinicians ensure that equipment will facilitate clear connections throughout the session and optimize communication.
• Communication Access Realtime Translation (CART; or Computer Assisted Realtime) transcribes and instantaneously captions spoken language to relay messages; CART provides access to services for individuals who are D/HOH.
• Apps and online translation allow for immediate translation. However, translation is more than merely word-for-word substitutions. Be cautious, as translation programs have not been proven to be a reliable source for quality translation.

Technology may be used to facilitate carryover and recall of strategies and techniques. Smartphones provide an opportunity to record spoken language and video signed languages to allow clients/patients/caregivers to revisit clinical recommendations.

Refusal of Services

At times, clients/patients/caregivers may refuse the assistance of an interpreter/transliterator. Clinicians consult with clients/patients/caregivers on the value of working with the assistance of the interpreter/transliterator in order to obtain the most accurate data. A signed release statement should be collected in cases where such services are declined.

On-Site Translation

All vital written documentation should be translated into the client's/patient's and/or family's preferred language, and clinicians should allow sufficient time for the translator to become familiar with these documents. Not all spoken or signed languages have written forms of communication.

There may be times when the interpreter or transliterator is asked to also provide translation services. However, translation requires different skills from interpreting and transliterating. Unless the interpreter is also a translator, the clinician should not expect this. Some qualified professional interpreters do not feel comfortable doing sight translation or written translation.

Software programs frequently look for verbatim substitutions and do not offer professional, reliable results. Interpreting and translating is not word-for-word substitution and may require more or fewer words to communicate an intended message as well as complete syntactic restructuring of sentences or even full paragraphs to maintain cohesion and coherence.

Assessment

The basis of an appropriate diagnosis of a communication disorder is a reliable, valid, and culturally and linguistically appropriate assessment. When conducting an assessment while collaborating with an interpreter, translator, or transliterator, clinicians

• ensure that the interpreter or transliterator comprehends the importance of not cuing, prompting, or modifying prompts in an assessment situation and
• recognize that, in many cases, words cannot merely be translated from English to the client's language (i.e., assessment lists for audiologic evaluations utilizing speech reception testing [SRT] are based on frequently occurring sounds in English).

Selection of appropriate assessment tools is based on the needs of the client/patient and the presenting concerns. Currently, only a limited number of tests have been translated, and an even smaller number of those assessments have been standardized for administration with the collaboration of an interpreter.

Prepared or on-site translation of formal assessments that have been standardized on English-speaking populations may provide the opportunity to gather information in a structured manner. However, the clinician must critically evaluate the validity of the translated materials. For example, speech sound elicitation materials may not elicit the same sounds, and allophonic variation will differ across languages; subject omission is acceptable in Spanish but not English, so in a sentence repetition task, take great care in how the data are used. Written permission is to be obtained from the test publisher before test materials can be translated for either a clinician's individual use or for dissemination of the translated version of the test for use on a wider scale (i.e., clinical program, district, or research group). In these circumstances, it is not appropriate to report standard scores.

Intervention

The intervention process and subsequent ongoing consultation allow for more prompting and feedback than assessment. Effective intervention also takes the cultural significance and relevance of goals into account. Therefore, it becomes critical for the clinician to share the overall goals of intervention sessions with the interpreter to optimize service delivery. When working with an interpreter or transliterator, the clinician does the following:

• Considers the client's experience during the assessment process and, if possible, collaborates with the same interpreter or transliterator from assessment through intervention, as appropriate.
• Explains to the interpreter or transliterator why and how various activities and exercises assist the client. Providing context for an activity is often helpful in accomplishing goals.
• Understands that the role of the interpreter is to convey meaning—and, sometimes, there is not an equivalent word that can be translated. For example, in familiar word pairings used in a conceptual activity, the term “peanut butter and jelly” may not be culturally relevant to the client.

Engagement of family members may facilitate a carryover of clinical objectives and strategies to a functional environment that is beneficial to the client's progress. Intervention plans may include components on how to engage the family members and how the family will support the client in the home. The clinician considers communication preferences and interpretation/transliteration/translation needs for family members and caregivers, as well.

Documentation

Collaboration with an interpreter, transliterator, or translator and any observations regarding the impact of this collaboration on assessment and intervention findings should be documented in reports and submissions for insurance claims. Use of translated materials should also be indicated. This documentation provides an accurate record of clinical interaction and a legal record of the services provided. It also provides evidence of ethical conduct, consistent with Principle of Ethics I, Rules B and C (ASHA, 2016).

Legal and Ethical Concerns

Legal and ethical considerations are foundational to appropriate services. There may be times when services meet legal (local, state, federal) regulations/requirements but do not meet the fundamentals of ethical conduct. Codes of ethics or professional conduct are principles designed to help professionals conduct business honestly and with integrity, and are generally aspirational in nature. It is critical that clinicians have a working knowledge of both legal and professional ethics standards (i.e., practicing anti-discrimination in the provision of services, ensuring patient privacy)—as they pertain to working with interpreters, transliterators, and translators—to ensure appropriate clinical interactions.

State and Federal Legislation

State and federal regulations, along with industry standards, mandate equal access to services regardless of language used. A number of state and federal regulations have implications for audiologists and SLPs collaborating with interpreters, transliterators, and translators.

Rights to linguistic access to services may come from multiple pieces of legislation. “In 2008, all 50 states had at least two laws in place on language services in healthcare settings” (Au, Taylor, & Gold, 2009, p. 2). Differences in state regulations may be reflected in a number of requirements. See ASHA's state-by-state page for a summary of state requirements.

Executive Order 13,166

Executive Order 13,166 was signed in 2000 to provide guidance to federal agencies on the enforcement of Title VI of the Civil Rights Act of 1964 as it pertains to language access. It reminds agencies receiving federal funding that “health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner, during all hours of operation” (Youdelman, 2008, para. 6). The guidance provided applies to any health care provider or entity that receives federal funding, including

• Medicare Part A;
• federally funded clinical trials;
• Children's Health Insurance Program (CHIP); and
• Medicaid.

Failure to ensure equal access may result in loss of funding.

Americans with Disabilities Act

The Americans with Disabilities Act of 1990 prohibits discrimination and ensures equal opportunity for persons with disabilities in the areas of employment, state and local government services, public accommodations, commercial facilities, and transportation. Congress has mandated the need for auxiliary aids and services—such as interpreters, transliterators, and translators—to ensure equal opportunity for individuals with disabilities (Americans with Disabilities Act of 1990). A language difference alone is not a disability. To confirm compliance, consult ADA's Checklist for General Effective Communication.

Equal Educational Opportunities Act of 1974

The Equal Educational Opportunities Act of 1974 states, “All children enrolled in public schools are entitled to equal educational opportunity without regard to race, color, sex, or national origin.” No state can deny students the right to equal education by “failure by an educational agency to take ‘appropriate action' to overcome language barriers that impede equal participation by its students in its instructional programs” (Equal Educational Opportunities Act of 1974).

Individuals with Disabilities Education Act (IDEA)

For school-age children, the Individuals with Disabilities Education Act of 1990 (IDEA) was enacted to ensure that all children with disabilities (age 3–21) have available to them a free and appropriate public education (FAPE) that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living.

Part B

IDEA states that, in the development, review, and revision of an IEP, the team must consider several factors with regards to interpreters:

(iv) Consider the communication needs of the child, and in the case of the child who is D/HOH, consider the language and communication needs, opportunities for direct communication with peers and professionals in the child's language and communication mode, academic level, and full range of needs including opportunities for direct instruction in the child's language and communication mode, and (v) Consider whether the child requires assistive communication devices and services. [IDEA § 1414(d)(3)(B)]

Parents and IEP teams assign or hire an interpreter on the basis of the child's mode of communication. Specifically,

[i]nterpreting services, as used with respect to children who are deaf or hard of hearing, includes oral transliteration services, cued language transliteration services, and sign language interpreting services. [IDEA, 34 C.F.R. 300.34(c)(4)]

Services for children who are learning English as a second language must take the language(s) of the home into consideration for both assessment and intervention. For children who receive services with an IEP under Part B (age 3–21), “When evaluating English language learner (ELL) students, it is important for speech-language pathologists (SLPs) to carefully review the child's language history to determine the language of assessment. If it is determined that the child should be evaluated in a language other than English, the SLP must use all available resources, including interpreters when necessary, to appropriately evaluate the child” (ASHA, n.d.-a, para 4).

Part C

For children who receive services with an Individualized Family Service Plan (IFSP) under Part C (birth–2):

Language added to §§ 303.321(a)(5) and 303.321(a)(6) states that all evaluations and assessments of a child must be conducted in the native language of the child, in accordance with the definition of native language in § 303.25, unless clearly not feasible to do so. While the phrase ‘unless clearly not feasible to do so' was inserted to acknowledge that there may be instances where conducting an assessment in the child's native language is not possible, the U.S. Department of Education, in the discussion section of the final regulations, clarifies that best efforts should be put forth to locate an on-site or telephonic interpreter when needed. (ASHA, n.d.-b)

Native language, as defined in § 303.25(a)(1) of IDEA, means “the language normally used by that individual, or in the case of a child, the language normally used by the parents of the child.”

HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides national standards to protect the privacy of personal health information. Some regulations include provisions related to service providers working with interpreters, transliterators, and translators.

HIPAA allows covered health care providers to share a client/patient's health information with an interpreter without the patient's written authorization under the following circumstances:

• A health care provider may share information with an interpreter (e.g., a bilingual employee, a contract interpreter on staff, or a volunteer) who works for the provider.
• A health care provider may share information with an interpreter who is acting on its behalf (but who is not a member of the provider's workforce) if the health care provider has a written contract or other agreement with the interpreter that meets HIPAA's business associate contract requirements.
• A health care provider may share information with an interpreter who is the patient's family member, friend, or other person identified by the patient as their interpreter, provided that (a) the patient agrees, or does not object, or (b) the health care provider determines, using their professional judgment, that the patient does not object.

Health Care and Organization Standards

The Joint Commission accredits and certifies health care organizations and programs in the United States. Patient-centered communication standards for hospitals are published in the Comprehensive Accreditation Manual for Hospitals (CAMH; The Joint Commission, n.d.). The standards address issues such as qualifications for language interpreters and translators, identifying and addressing patient communication needs, collecting patient race and ethnicity data, patient access to a support individual, and nondiscrimination in care.

National CLAS Standards

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (Office of Minority Health, n.d.) are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health care organizations to implement culturally and linguistically appropriate services. Although these guidelines are not federal law, they are recommended by the U.S. Department of Health and Human Services, Office of Minority Health. With regards to communications and language assistance, the CLAS standards seek to

• offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services;
• clearly inform all individuals of the availability of language assistance services in their preferred language, verbally and in writing;
• ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided; and
• provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Ethics

ASHA's Code of Ethics (2023) provides the fundamentals of ethical conduct. Principles of Ethics and Rules of Ethics are specific statements of minimally acceptable as well as unacceptable professional conduct—and are applicable to all individuals who are ASHA members and/or certificate holders or who are applicants for membership and/or certification.

The service provider is responsible for understanding cultural and linguistic issues that may impact treatment. For further information please see ASHA’s Practice Portal page on Cultural Responsiveness.

Although providing services to linguistically diverse individuals may require the assistance of trained interpreters or other multilingual professionals, it is the responsibility of the professional to understand the influence of issues related to cultural and linguistic diversity (e.g., second language acquisition, dialectal differences, multilingualism). Ultimately, the professional is responsible for the appropriate diagnosis and treatment/management of communication disorders, communication differences, communication disorders within communication differences, as well as of swallowing and balance disorders.

Periodically, the Board of Ethics develops Issues in Ethics Statements when further clarification and guidance are needed to assist in ethical service delivery. The Issues in Ethics statement, Cultural and Linguistic Competence, specifically addresses the use of interpreters for the provision of services (ASHA, 2017).

Case Studies

Case studies may serve to illustrate the complex decision-making process, as clinicians strive to provide the most appropriate services to individuals who do not use spoken English in the home.

Case Study 1

Rosita is 3 years, 8 months old. They came to the United States from Mexico 6 months ago with their parents and 1-year-old brother. Spanish is the language used at home. Five months ago, they enrolled in a Head Start preschool where only a few staff members speak Spanish. Many of the students also are native Spanish speakers. Three months after Rosita began preschool, their teacher referred them for a speech and language assessment. This is the first year that the SLP, who speaks only English, is providing services at this preschool. The SLP recently completed their clinical fellowship at a neighborhood school, and their mentor has moved out of state. The preschool director, also a monolingual English speaker, spent most of their long career at an elementary school where most students spoke only English. The SLP knows that they should not proceed without an interpreter. The school uses the teaching assistant, whose son attends the preschool, to assist with as-needed interpreting. The assistant is not a trained interpreter and is not comfortable with their own English skills. The SLP has taken their concerns to the director who, although sympathetic to the situation, is insistent that the SLP complete the evaluation.

Discussion

The administrators of Head Start programs are legally responsible for ensuring the appropriate provision of services per Title VI of the Civil Rights Act of 1964. Given that the SLP is monolingual, adherence to the law would call for working with the assistance of an interpreter. The law does not specify the training and/or qualifications of the interpreter. ASHA's Principle of Ethics I, Rule B, states, “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.” In order to ensure that they are meeting this requirement, the SLP may do two things: (1) seek out a trained interpreter or (2) provide training to the bilingual assistant to ensure high-quality services.

(as adapted from Chabon, Brown, Gildersleeve-Neumann, 2010)

Case Study 2

A clinician's supervisor asks them to evaluate a Cantonese-speaking 7-year-old girl. The girl's family came from China. No Cantonese-speaking SLP is available in the district, so the clinician evaluates them through an interpreter. This interpreter knows the dialect spoken by the child and understands the purpose of a speech-language evaluation and their role in the evaluation. The clinician knows of no standardized speech-language tests in Cantonese, and they know it is inappropriate to report scores on translated tests. They have kept up to date on all related research, and their evaluation is consistent with current preferred practice guidelines for the assessment of bilingual/bicultural children.

A few days after the clinician submits their evaluation, they receive a phone call. Their district has rejected their evaluation because test scores have not been not reported. They explain that translated tests are invalid because they do not take into account differences between the two languages. They also explain that the assessment procedures they followed provide an appropriate assessment of the child's communication skills.

Their district supervisor, however, reminds them that, up until this point, they and every other SLP in the district have provided test scores. These scores, the district supervisor explains, were an easy way to see a child's level of performance to determine eligibility for services. So, the clinician must go back, retest the child using a translated test, and report those test scores.

The ethical dilemma: Does the clinician go back with their interpreter, have them translate the tests, and then determine eligibility based upon the child's scores?

Discussion

According to IDEA, there is a need to demonstrate academic impact and the absence or presence of a disability. A number of different measures may be used. There are no legal requirements that standard scores must be used to qualify an individual to receive services.

Principle of Ethics II indicates that “Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance” (ASHA, 2016). The clinician would not be honoring this responsibility if they knowingly uses standard scores from a translated version of an assessment that has not been validated on a population representative of the individual tested

(as adapted from Crowley, 2004).

Case Study 3

An audiologist who is employed at a hospital is working with an individual who uses cued speech to communicate. The audiologist knows that cued speech is the preferred communication system used by the client but does not have any information about how the individual best understands or uses written language. The audiologist has prepared some written reports to provide to the patient about the assessment results. The audiologist provides the patient with a written copy of the report without any additional support because cued speech is not a language in and of itself and is based on spoken English.

Discussion

Legally, all materials must be presented to the patient in their preferred language. In addition to legal requirements, the Joint Commission requires that patient intake forms request preferred language. Signed languages and manual communication systems do not have a written language component. English is often the presumed form of preferred written language; however, it may not be. It may be necessary to supplement written documentation with a cued speech transliterator in order to ensure comprehension. To ensure the best mode of communication, the preferred written language should be requested.

Case Study 4

A child who speaks Russian in the home exclusively is referred to an SLP. An interpreter was provided for the assessment, and the SLP determined that the child has a language disorder. The school administration and teachers want the SLP to provide intervention services in English only—because that is the language of the school. The SLP has concerns that this will not be sufficient to address the child's needs. What is the most ethical thing to do moving forward?

Discussion

IDEA states that the language of intervention should be the language most likely to yield the most accurate results. Although English is the language of the school in most cases, the language disorders of children who do not speak English can best be remediated in a language that they are familiar with. Executive Order 13,166 (2000) stipulates that agencies receiving public funding provide equal access to services regardless of language spoken. It is important that the SLP advocate for the most appropriate resources required to work with this child.

ASHA Resources

• IDEA Part B Issue Brief: Interpreting Services for the Deaf or Hard of Hearing
• Meeting the Needs of Limited English Proficiency Patients
• Palliative and End-of-Life Care
• SIG 16 Perspectives: Working with Interpreters to Support Students Who Are English Language Learners
• SIGnatures: Integrating an Interpreter

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• Classroom Interpreting
• Guide to the Privacy and Security of Electronic Health Information
• National Board of Certification for Medical Interpreters
• Nine Best Practices for Using an Interpreter for ASQ Completion
• Registry of Interpreters for the Deaf
  • State-by-State Regulations
• Testing, Evaluation, and Certification Unit for Cued Language Transliterators
• Tips for Working With Interpreters in Early Intervention Settings
• Tips for Working With Sign Language Interpreters

Americans with Disabilities Act of 1990, Pub. L. No. 101-336, 42 U.S.C. §§ 201 et seq.

American Speech-Language-Hearing Association. (n.d.-a). IDEA Part B Issue Brief: Culturally and linguistically diverse students. Retrieved from www.asha.org/Advocacy/federal/idea/IDEA-Part-B-Issue-Brief-Culturally-and-Linguistically-Diverse-Students/

American Speech-Language-Hearing Association. (n.d.-b). IDEA Part C Issue Brief: Cultural and linguistic diversity. Retrieved from www.asha.org/Advocacy/federal/idea/IDEA-Part-C-Issue-Brief-Cultural-and-Linguistic-Diversity/

American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Retrieved from www.asha.org/policy/

American Speech-Language-Hearing Association. (2017). Issues in ethics: Cultural and linguistic competence. Retrieved from www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/

Au, M., Taylor, E. F., & Gold, M. (2009). Improving access to language services in health care: A look at national and state efforts. Washington, DC: Mathemathica Policy Research.

Chabon, S., Brown, J. E., & Gildersleeve-Neumann, C. (2010). Ethics, equity, and English-language learners: A decision-making framework. The ASHA Leader, 15(9), 10–13. Retrieved from http://leader.pubs.asha.org/article.aspx?articleid=2291867

Civil Rights Act of 1964. Pub. L. 88-352, 20 USC §§ 241 et seq.

Crowley, C. J. (2004). The ethics of assessment with culturally and linguistically diverse populations. The ASHA Leader, 9(5), 6–7. Retrieved from http://leader.pubs.asha.org/article.aspx?articleid=2292291

Equal Educational Opportunities Act of 1974. Pub. L. 93-380 20 U.S.C. § 1701–1758.

Exec. Order No. 13,166, 3 C.F.R. 50121–50122 (2000).

Federal Policy for the Protection of Human Subjects, 45 C.F.R. § 46 (2001).

Gambino, C. (2016). Inside the American Community Survey: 2016 language data overhaul. Retrieved from https://www.census.gov/newsroom/blogs/random-samplings/2017/09/inside_the_american.html

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 42 U.S.C. §§ 201 et seq.

Individuals with Disabilities Education Act of 1990, Pub. L. No. 101-476 20 U.S.C. §§ 1400 et seq.

The Joint Commission. (n.d.). Comprehensive accreditation manual for hospitals. Oak Brook, IL: Author. Retrieved from https://www.jointcommission.org/

Langdon, H. (2002). Interpreters and translators in communication disorders. Eau Claire, WI: Thinking Publications.

Langdon, H. W., & Saenz, T. I. (Eds.). (2016).Working with interpreters and translators: A guide for speech-language pathologists and audiologists. San Diego, CA: Plural Publishing.

National Cued Speech Association. (2006). A quick overview of cued speech. Retrieved from http://www.cuedspeech.org/pdfs/facts/Cued-Speech-Overview.pdf

Office of Minority Health. (n.d.). National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Retrieved from https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf

Orellana, M. F., Martínez, D. C., & Martínez, R. A. (2014). Language brokering and trans-languaging: Lessons on leveraging students' linguistic competencies. Language Arts, 91(5), 311–312.

Ostergren, J. A. (2014). Speech-language pathology assistants: A resource manual. San Diego, CA. Plural Publishing.

Registry of Interpreters for the Deaf. (2007). Oral transliteration standard practice paper. Retrieved from https://drive.google.com/file/d/0B3DKvZMflFLdRjdralozSG1iSG8/view

Torres, K., Lee, N., & Tran, C. (2015). Building relationships building cultures: Cultural brokering in family engagement [The Equitable Parent-School Collaboration Research Project Publication Series]. Retrieved from https://education.uw.edu/sites/default/files/programs/epsc/Cultural%20Brokers%20Brief_Web.pdf

U.S. Department of Justice & U.S. Department of Education. (n.d.). Ensuring English learner students can participate meaningfully and equally in educational programs.Retrieved from https://www2.ed.gov/about/offices/list/ocr/docs/dcl-factsheet-el-students-201501.pdf

Youdelman, M. K. (2008). The medical tongue: U.S. laws and policies on language access. Health Affairs, 27(2), 424–433. Retrieved from https://www.healthaffairs.org/doi/10.1377/hlthaff.27.2.424

Acknowledgements 

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Collaborating with Interpreters, Transliterators, and Translators page:

• Nancy Castilleja, MA, CCC-SLP
• Linda Jarmulowicz, PhD, CCC-SLP
• Ellen Kester, PhD, CCC-SLP
• Katherine Langan, PhD
• Henriette Langdon, PhD, CCC-SLP
• Edgarita Long, PhD, CCC-SLP
• Karen Munoz, EdD, CCC-A
• Karin Ruschke, MA
• Terry Saenz, PhD, CCC-SLP
• Brenda Seal, PhD, CCC-SLP
• Kenneth Wolf, PhD, CCC-A

In addition, ASHA thanks the members of the Ad Hoc Committee on Supervision in Speech-Language Pathology, whose work was foundational to the development of this content.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Collaborating with Interpreters, Transliterators, and Translators. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Collaborating-With-Interpreters/