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Research Article
Folia Phoniatr Logop 2019;71:116–126
Speech and Language Therapy Services for
Multilingual Children with Migration Background:
A Cross-Sectional Survey in Germany
Wiebke Scharff Rethfeldt
Hochschule Bremen, City University of Applied Sciences Bremen, Bremen, Germany
Received: March 7, 2018
Accepted: November 18, 2018
Published online: May 14, 2019
Prof. Dr. Wiebke Scharff Rethfeldt
Head of Applied Therapeutic Sciences, Speech and Language Therapy, Faculty 3
Social Sciences, Hochschule Bremen, City University of Applied Sciences Bremen
Neustadtswall 30, DE–28199 Bremen (Germany)
E-Mail w.scharff.rethfeldt @ hs-bremen.de
© 2019 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/fpl
DOI: 10.1159/000495565
Keywords
Speech and language therapy service provision ·
Multilingual children · Misdiagnosis · Diversity ·
Socioeconomic status · Developmental language disorders
Abstract
Speech, language, and communication needs are particu-
larly common among multilingual and migrant children.
More than every third child in Germany has a migrant back-
ground. In the city of Bremen, this figure is even higher, in-
cluding refugee children. The availability of comprehensive
data on the provision and uptake of speech and language
therapy (SLT) services is still inadequate, especially for mul-
tilingual children. However, health-monitoring programs re-
port that migrants differ in many health-related areas from
the majority population, mainly in barriers in health care.
This study examines the current provision of SLT services for
multilingual children following a medical prescription for
the specific case of suspected language disorder. Informa-
tion was obtained from speech-language pathologists (SLPs)
representing 28 practices in different districts across one of
the moderately largest cities affected by sociospatial polar-
ization. The SLT practices were clustered according to the
proportion of minor migrants and minor welfare recipients
in the district. The survey included the number and propor-
tion of multilingual children on the SLT caseloads, as well as
the age of children by time of referral, physician and SLP di-
agnoses, application and type of assessment materials, inter-
vention goals, and sociodemographic data of practicing
SLPs. Questionnaire responses were analyzed using descrip-
tive statistics and an explanatory interpretive approach.
Findings suggest that multilingual children experience later
referral compared to monolingual German-speaking chil-
dren, with approximately half of the multilingual children
demonstrating a developmental language disorder (DLD).
The SLP’s level of experience determines the accuracy of dif-
ferential diagnosis between communication disorders and
typical linguistic variations. Consequently, participation in
continuing education focusing on service provision of the
multilingual and multicultural clientele is essential. This
study highlights the obstacles and the needs for increased
multiprofessional awareness and an enhanced professional
knowledge to provide effective and swift diagnosis earlier to
allow multilingual children with a DLD to access relevant ser-
vices on equal terms with native resident children.
© 2019 S. Karger AG, Basel
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SLT Services for Multilingual Children
with Migration Background
117
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DOI: 10.1159/000495565
Introduction
The Changing Demography of Migrant Populations
A changing demography and structural changes con-
tinue to provide the framework for the working field of
speech and language therapists (SLTs) in Germany,
where migration has a major impact on assessment and
intervention. Germany has experienced large-scale im-
migration since World War II. In 2016, Germany’s total
population was estimated to stand at 82.5 million, with
a growth of 1.14 million people or +1.2% within 1 year
due to immigration from diverse countries. The migrant
proportion of the population reached 22.5% [1]. The
proportion of children aged under 10 years with a mi-
gration background has grown to more than one third
of the overall population, and in some urban areas the
figure is more than 50% [1]. The term “migration back-
ground” officially does not only focus on immigrants as
such but includes certain descendants who were born in
Germany as well. It is important to differentiate between
citizenship and migration background, as only about
half of these people possess foreign citizenship. Al-
though Europe continues to be the most important re-
gion of origin, other continents, especially Africa, have
become more important with regard to immigration
over recent years.
Migration has led to a high variety of cultural and lin-
guistic diversity. Migrant and refugee children grow up
with multiple and opaque experiences concerning the
patterns of exposure, attrition, or change of languages in
their environment. This variability is due to linguistic di-
versity among caregivers, change of caregivers, change of
habitat, and the quantity and quality of exposure over
time. Consequently, using the standard terminology of
simultaneous and sequential bilingualism to refer to the
age of exposure is considered inappropriate as this may
lead to incorrect assumptions and interpretations [2].
Not claiming to explore the myriad of terminological is-
sues of bilingualism and multilingualism, bilingual (in-
cluding multilingual) children may be broadly defined
following the Royal College of Speech and Language
Therapists’ (RCSLT) definition as “individuals or groups
of people who acquire communicative skills in more than
one language … with varying degrees of proficiency, in
oral and/or written forms, in order to interact with speak-
ers of one or more languages at home and in society …
regardless of the relative proficiency of the languages un-
derstood or used” [3, p. 268]. With regard to this study,
the terms bilingualism and multilingualism are being
used interchangeably.
Although people with a migration background, in-
cluding second or third generation migrants, may differ
culturally and linguistically, most share a common char-
acteristic of continued disadvantages compared to those
without a migrant background in terms of education,
participation, and income [1]. The language use of people
with a migration background varies. Even many adults
lack standard or even minimally proficient German,
which is argued to be one of the major obstacles to their
integration. Thus, second or third generation migrant
children are exposed to German less frequently and they
often lack proficiency when they enter school [4, p. 17].
The high and growing number of persons with a migrant
background among the younger populations entails new
challenges for health care service institutions as well as
preschool and school education settings in large cities.
The needs of health care will increase according to the
significant growth of the population in Germany. This
will result in higher numbers and demands associated
with a greater number of multilingual children in SLT
caseloads [5, 6].
The Challenge of Differential Diagnosis
The cultural and linguistic diversity of the current
population living in Germany presents clinicians with
new issues [7]. Multilingual, especially migrant, children
with speech and language difficulties are presented in var-
ious areas of the health, social, and educational systems.
However, these systems differ in their organizational
structures and in understanding and list of measures con-
cerning children with speech, language, and communica-
tion needs (SLCN). Health and education systems in Ger-
many are structurally separated, making communication
and collaboration more difficult. Speech-language pa-
thologists (SLPs) working in outpatient practice require
a prescription for assessment and intervention from a
medical doctor. Consequently, this requires the coopera-
tion of medical individuals. Clinical assessment and in-
tervention is not offered in daycare centers and schools.
Thus, these children may not receive adequate support
for their needs.
The distinction between differentiating typical from
atypical language development may not occur reliably, as
there may be multilingual children who have SLCN, a
term that is largely associated with insufficient experience
with a new language [8]. In contrast, some children may
present with a developmental language disorder (DLD) or
language disorder associated with a known biomedical
etiology. These children are likely to experience lifelong
difficulties with their communication skills if not receiv-
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DOI: 10.1159/000495565
ing therapeutic intervention. Learning a new language
generally does not cause language problems. Thus, multi-
lingual children should not be more or less likely to have
a DLD in comparison to the monolingual population [9].
So far, data on the incidence and prevalence of language
disorders in the German population are missing. Interna-
tional epidemiological surveys converge in estimating the
total population prevalence of language disorders at 9.92%
[10] and the prevalence of DLD to be around 7% [11, 12].
However, as current prevalence estimates are based upon
the general population in the UK and the USA, these find-
ings must be regarded with caution, given the lack of reli-
able data on incidence and prevalence of language disor-
ders in the culturally diverse population in Germany.
The identification of a DLD is particularly challenging
in multilinguals [11], as educational and clinical profes-
sionals are not fully familiar with multilingual children
with language disorders. This places multilingual children
at risk for misdiagnosis and interventions, such as early
intervention focusing on educational achievement instead
of individual therapy. There is still an insufficient number
of qualified multilingual clinicians, and a lack of system-
atic diagnostic tools, as standardized tests are generally
biased in favor of individuals from the majority culture.
This especially accounts for multilingual children with
suspected DLD as language difficulties are not associated
with a known biomedical condition [13]. Since there is no
robust normative data for the tremendously diverse popu-
lation of multilingual children, there is a higher risk that
language assessments may overidentify, but also underi-
dentify, or misidentify multilingual children [14].
Current literature recommends that clinical approach-
es and assessment in multilingual children should be
based on data collected from a variety of sources [15].
These include results from application of criterion-refer-
enced measures [16], language-processing measures [17,
18], dynamic assessment [19] integrated within sociocul-
tural approaches [20], as well as detailed ethnographic
information. Moreover, applied clinical reasoning strate-
gies for choice of methods and interpretation of results
need the clinician to possess intercultural competencies
[21]. Although assessment procedures with multilingual
children have been well described, the realities of practice
are still very different from the suggested evidence-based
frameworks.
Decrease in Medical Prescriptions for SLT
The proportion of young people with a migration
background has dramatically increased since 2014. None-
theless, the rate of children and adolescents who receive
SLT has slightly decreased [22]. There are marked region-
al differences in prescription rates and therefore in utili-
zation of SLT services. While the national average pro-
portion for children aged less than 14 years was 12%, only
10% of the insured children in the state of Bremen have
seen an SLT, with DLD being the most frequent diagnosis
[22, p. 33]. It is also noteworthy that, compared to chil-
dren without a migration background, migrant children
consult a pediatrician significantly less often [23].
Statement of Problem
Numerous studies have shown that the population
with a migrant background has a higher risk of poverty
compared to native Germans, even if holding citizenship
[24]. The link between financial poverty and health status
and well-being has also been demonstrated in several
studies [6]. In addition, research on access to health care
services and preventive behaviors suggests that inade-
quate language skills in children may aggravate existing
health problems at the age of 6 years and lead to cumula-
tive health and social disadvantage [7]. Understanding
how multilingualism and socioeconomic status (SES) in-
teract in immigrant societies with diverse competencies
in health care and education systems, and how this may
enhance the risk of misdiagnoses, remains a major chal-
lenge.
Study Objectives
With reference to the repeatedly discussed migrant-
specific issue of access to health care services in relation
to SES, the MeKi-SES project (Mehrsprachige Kinder mit
Sprachentwicklungsstörung; “Multilingual Children with
Developmental Language Disorder”) was initiated. Since
access to SLT in Germany requires a medical prescrip-
tion, the main objective of the study was to determine
which factors place multilingual children at a higher risk
of a lack of access to SLT provision. This study examines
the current provision of SLT services for multilingual
children following a medical prescription for the specific
case of suspected language disorder. To identify those
multilingual migrants at risk of developing a language
disorder and to assist with the assessment and treatment
of multilingual children in general, the present study fo-
cused on multilingual children undergoing SLT. Conse-
quently, specific aims of the study were to (a) to collect
sociodemographic data on SLPs offering services to mul-
tilingual children including sociospatial information, (b)
to establish data on the referral of multilingual children
to SLT services in outpatient caseloads, (c) to determine
which measures are used when assessing multilingual
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DOI: 10.1159/000495565
children with suspected language disorder, and (d) to
gauge SLTs’ opinions and estimates regarding their
framework conditions relevant for multilingual and mi-
grant children.
Methods
Research Design
A cross-sectional survey was conducted in the German city of
Bremen, where the proportion of people with a migrant back-
ground was 29.4% [25]. This urban setting is characterized by so-
ciospatial segregation, resulting in a division into identifiable areas
distinguished by poverty rates (including child poverty in house-
holds defined by welfare recipient status) and by the proportion of
the population that are migrants.
Participants
Between May and July 2016 all listed SLT practices across the
city of Bremen were contacted using the telephone directory and
online practice portal. Approximately half of the advertised prac-
tices were no longer offering SLT services. The recruitment crite-
rion was that the practice had to include at least one SLP, speech
therapist, clinical linguist, or a state-certified breath, speech and
voice teacher – all professions that fulfill the approval require-
ments of the national health insurance agency to offer SLT ser-
vices to the general public. Provision of specialized services to mul-
tilingual patients was not required. In sum, data of 30 SLT prac-
tices were collected. Two SLT practices reported that they are
specialized in working with an elderly population exclusively, so
they were excluded from this study. Since this study focuses on
services for children, further findings are based on data from the
remaining 28 SLT practices.
Questionnaire Development
The data were collected by means of questionnaires. The con-
tent of the survey was developed through focus groups with seven
SLPs from diverse SLT practices across the city to determine their
practice settings, who were recruited following their participation
at a regional association meeting. Questions to be included were
devised on the basis of a literature review [3, 7, 20, 23] and in-depth
interviews. This produced a pilot version of the instrument which
was tested by an additional five SLPs in diverse SLT practices out-
side Bremen, and then revised by a group of six SLPs who work
part-time and continue their studies at the City University of Ap-
plied Sciences Bremen. Analysis of the responses and feedback re-
garding clarity and ambiguity of the questions resulted in a final
refinement, and the survey required approximately 45 min to com-
plete. Financial compensation was offered, equivalent to the stan-
dard fee for one therapy unit per practice.
Data Collection Procedures
The final version of the questionnaire was fully completed on-
line or by mail after individual consultation with regard to the pre-
ferred version. The questionnaire was available for a 10-week pe-
riod. The final sample for analysis of SLT provision for multilin-
gual children was analyzed using descriptive statistics (SPSS v24).
All practices were clustered according to their location, taking into
account the mean sociospatial values of the proportion of welfare
recipient households with children and the proportion of minors
with migrant background in their area. Quantiles were used as cut
points, dividing the city-wide probability distribution into four
equal-sized groups and creating the termed quarters A–D, in order
to apply the aforementioned proxy indicators of migration and
poverty.
Results
Sociodemographic Data of Clinicians
Data from submitted questionnaires of 30 SLT prac-
tices represented 72 clinicians with a mean age of 47 years
(SD = 7.7), while most (74%) of the surveyed clinicians
were 51 years of age or older. They had a mean of 17 years
of professional experience (SD = 7.3). In one third of the
practices surveyed, service is offered by one clinician
only. All surveyed practices have been established for at
least 3 years, while the majority (52%) of the practices
have been offering services for more than 15 years. Two
practices reported that they are specialized in working
with an elderly population exclusively, so they were ex-
cluded from the study. Since this study focuses on ser-
vices for children, further findings are based on data from
the remaining 28 SLT practices.
Nearly half of the surveyed SLT practices (47%) re-
ported that they use German exclusively to make contact
for intervention including consultations, informed con-
sent discussions, and education talks with caregivers. An-
other 44% of the clinicians said that they use English
when assessment and intervention is not possible in Ger-
man. In 3 of the practices, one of the clinicians also speaks
Russian, Turkish, or Polish with their patient and/or care-
givers. More than half of the respondents (57%) said that
they had received additional education or attended a
training course in the field of childhood multilingualism.
Sociospatial Location
SLT practices from all sociospatial areas were includ-
ed in this study (Fig.1, 2). With the city-wide proportion
of the migrant population in the under 18 age group
standing at 53.3% [25], the average number of children
with migrant background in the surveyed practices is
49% and is therefore similar. Also, the practices can be
assigned to areas in which the proportion of welfare re-
cipient households with children under 15 years is on
average 24%, only a bit less than the city-wide share of
29% [25].
Taking into account the sociospatial polarization of
the city by the variables (1) proportion of the migrant
population aged under 18 (MPOPu18) and (2) propor-
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tion of welfare recipient households with children aged
under 15 (WRHCu15), the participating SLT practices
were clustered into four district groups (Table 1). This
allocation was made in accordance with the city-wide
average [25]. In examining Table 1, it can be seen that,
for example, district A is characterized by a higher rate
of migrant children and a higher rate of welfare recipi-
ent households with children compared to the city aver-
age.
Patient Cohort
The proportion of multilingual children with migrant
background in SLT practices (n = 635) corresponds, with
minor exceptions, to the proportion of minor migrants of
the SLT practice’s district. Based on the group of patients
by district, a slight to moderate correlation was revealed
(Cramer’s V = 0.37). Thus, the proportion of multilingual
children in such practices that are assigned to district
group A is significantly higher than those of district group
B. Overall, SLT practices have on their caseloads from
26% up to 86% multilingual children, depending on the
demographic composition of their neighborhood. There
was a moderate relationship (Cramer’s V = 0.25) between
the number of multilingual children at the time of the
survey present in SLT practices and the proportion of the
migrant population aged under 18 (districts A and C).
Referral
Out of all 28 SLT practices assessed, referrals for mul-
tilingual children to SLT are received from various medi-
cal doctors. All (100%) receive referrals from a pediatri-
cian, while many practices receive referrals from an ear-
nose-throat specialist (79%), an orthodontist (79%), a
phoniatrician (60%), a dentist (50%), and others such as
general practitioners (25%). The respondents indicated
that the mean age on referral was 4.3 years for monolin-
gual children, whereas the referral of multilingual chil-
dren was made 3 months later (mean age 4.6 years). Sig-
nificant gender differences were identified (p = 0.018).
Thus, the proportion of multilingual boys was almost
SLT practice
4.4–33.9%
34.0–50.0%
50.1–65.8%
65.9–96.3%
No data
Fig. 1. The sociospatial distribution of surveyed SLT practices across the city according to the proportion of the
migrant population aged under 18 (city average: 53.5%).
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twice as high, with an average number of 12 male versus
7 female multilingual children per SLT practice.
Among the surveyed SLT practices, 93% reported that
multilingual children were referred with a report of “lan-
guage disorder before completion of language develop-
ment” (SP 1). Half of the practices reported to receive
referrals of multilingual children for a (co-occurring)
“speech sound disorder” (SP 2). In addition, 40% of the
SLT practices’ caseloads of separate referrals for multilin-
gual children were for “fluency disorders” (RE 1).
SLT practice
0.0–11.3%
11.4–22.0%
22.1–38.0%
38.1–60.0%
No data
Fig. 2. The sociospatial distribution of the surveyed SLT practices across the city according to the proportion of
welfare recipient households with children aged under 15 (city average: 29%).
Table 1. Clustering of the surveyed SLT practices into four district groups according to their location with regard
to the sociospatial variables of the proportion of the migrant children population and the proportion of welfare
recipient households with children
District group
A B C D
Criteria according to city-wide average >MPOPu18
>WRHCu15
<MPOPu18
<WRHCu15
>MPOPu18
<WRHCu15
<MPOPu18
>WRHCu15
SLT practices, n9 16 3 2
MPOPu18, proportion of the migrant population aged under 18; WRHCu15, proportion of welfare recipient
households with children aged under 15.
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Assessment and Intervention
Upon referral of multilingual children with a suspected
DLD, clinicians reported on a multiple response question
that they used a broad range of assessment procedures.
Almost all of the surveyed clinicians (96.4%) reported
their primary assessments included observation and lan-
guage sampling from different settings such as spontane-
ous conversation or play. Most SLPs (92.8%) used pre-
assessment information by interviews on sociocultural
factors and language use and took case history informa-
tion in free conversation with accompanying caregivers.
More than a third (35.7%) of the clinicians used support
from interpreters or language mediators, while 19% of
them used questionnaires in diverse languages. When as-
sessing a multilingual child, 35.7% of the clinicians used
informal measures and 28.6% used German monolingual
norm-referenced standardized measures only; 35.7% of
the surveyed clinicians reported using a combination of
diverse approaches. Half of the SLPs (50%) used case his-
tory information compiled by a third party (e.g., kinder-
garten teacher following guardian’s consent), and 28.6%
used multi-professional reports in order to derive an SLT
diagnosis upon assessment of multilingual children.
It was reported that medical and SLT diagnoses were
not always congruent. In the case of the multilingual chil-
dren who were referred with the physician’s diagnosis of
a DLD, 57% were not treated for this after the SLP identi-
fied that they did not present with a language disorder.
Instead, the clinicians reported that they judged a need
for language support mostly due to a lack of knowledge
of German. In those cases where intervention with mul-
tilingual children had targets that differed from the med-
ical referral reason, 61% of the SLPs diagnosed other fun-
damental or more relevant disorders. As another reason
for their different treatment focus, 29% of the clinicians
explained that they found parental training was the prior-
ity need. Only 7% of the SLPs stated that they would al-
ways treat according to the medical indication. There was
a weak relationship between the number of clinicians
working in a practice and the critical examination of
medical indication (Cramer’s V = 0.20), that is, clinicians
in practices allowing team meetings to reflect upon clini-
cal decision making compared to one-person SLT prac-
tices. In particular, the establishment of a requirement for
language support contrary to a medical indication of a
DLD was disproportionately reported by the 2 SLT prac-
tices established in district D, that is, in an environment
containing a population with a migrant background be-
low the city-wide average but above average in terms of
the proportion receiving welfare.
SLP Assessment of the Child’s Needs
About half of the SLP respondents (53%) agreed, some
even strongly agreed (13%), while some disagreed (20%)
that the number of therapy sessions prescribed by the re-
ferral agent was sufficient for the multilingual children
with migrant background and DLD. Only a few clinicians
(13%) were undecided. Many clinicians also rated the
particular risk of an educational disadvantage for these
children as very high (60%) or high (23%), while others
rated the risk as either average (10%) or low (7%). The
majority of clinicians considered the prediction that mul-
tilingual children with migrant background and DLD
face social problems and are at a high risk of stigmatiza-
tion as high (30%) or very high (47%), while others rated
the risk as either average (17%) or low (7%). Overall, 40%
of respondents assessed access to treatment options for
multilingual children with a DLD as currently being un-
satisfactory, while 33% considered options as satisfactory,
and 13% rated the available options as very satisfactory;
another 13% were undecided. Overall, most of the re-
spondents rated the availability of consultation and edu-
cation information for caregivers of multilingual children
with migrant background and DLD to support SLT ser-
vices as being low (38%) or moderate (45%), while few
clinicians considered the availability of patient informa-
tion as either high (8%) or not at all (8%).
Discussion
In the present study, the provision and uptake of SLT
services for multilingual children with migration back-
ground in a setting characterized by sociospatial segrega-
tion were analyzed for the first time, thus providing pre-
liminary insights into SLP caseloads. This helps us to
identify whether multilingual children are put at a higher
risk of not receiving appropriate SLT assessments and in-
terventions. The survey was developed to collect sociode-
mographic data on clinicians offering services to multi-
lingual children and to establish data on this patient pop-
ulation in SLT outpatient practices. In addition, the study
aimed to determine SLP practices with multilingual chil-
dren, to identify their typical assessment approaches, and
to understand the reasons for the occurrence of misdiag-
nosis and/or inappropriate case management. Finally, it
aimed to gauge the opinions of SLPs and estimates in re-
lation to their working situation.
Due to the lack of findings from comparative surveys
as well as documentation in published databases, the re-
sults presented here still need to be replicated in further
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research. Since the city of Bremen has such a high level of
children with a migrant background (53.3%) [25], and
since the sample in this case study represents at least half
of all outpatient SLT practices established across the city
of Bremen, the reported results can be considered to be
broadly reflective of the national situation of urban mi-
gration in Germany.
The sociodemographic data of the clinicians in this
study show that the majority of the SLPs currently serving
the pediatric population are likely to retire from the work-
force before 2025. This finding is similar to estimates
based on surveys of the total workforce, in particular sec-
ondary services, which revealed similar demographic
trends leading to imminent shortages of skilled profes-
sionals in the health care sector [26]. Possible explana-
tions for the low number of younger SLT employees in-
clude less attractive working conditions, such as low wag-
es, and the high proportion of women experiencing
incompatibility between family and work. In contrast to
other member states of the European Union, SLT in Ger-
many is not yet a fully academically qualified occupation.
Consequently, as the data show a clear tendency towards
a decreasing SLT provision in general, this will addition-
ally impact on the multilingual and migrant population.
It can be seen that the surveyed SLT practices map the
sociospatial area well, since half of the practices are lo-
cated in districts where both the proportion of welfare
recipient households with children and the proportion of
the child migrant population are above average. This
sociospatial polarization based on the factors of poverty
and migration background is considered an appropriate
proxy indicator for variability in the uptake of SLT ser-
vices. The gender composition of multilingual children
with a language disorder present in the surveyed prac-
tices is in line with international prevalence estimates
[11]. The current findings confirm the moderate support
for a greater rate of language disorders among males than
females, although it is important to bear in mind the pos-
sible bias as samples do not represent incidence but prev-
alence on SLT caseloads. Overall, a high proportion of
multilingual children with migrant background on SLT
caseloads were revealed. The referred proportion seems
to be appropriate in relation to their representation in the
local population. However, in comparison to their mono-
lingual peers, multilingual children experience later re-
ferral of 3 months, a noteworthy delay in this preschool
age group. The later referral may be attributable to diverse
reasons. As previous studies identified an interaction be-
tween SES, migrant background, language differences,
and access-resource barriers [7, 23], it is likely to result
from language barriers and a disparity of access to medi-
cal care and subsequently prescribed SLT assessment and
intervention. As another possible reason, it cannot be
ruled out that a later referral due to belated appearance is
an expression of a previously recognized underdiagnosis
by the physician or related to a type of compensation. A
closer examination of disparities, including collecting,
analyzing, and monitoring ethnic and also language data
on all compulsorily national health care-insured chil-
dren, is needed to disentangle these compounding fac-
tors. This also accounts for the diverse medical profes-
sions that prescribe SLT, which need to be taken into ac-
count in order to enhance multiprofessional collaboration.
The necessity for a close collaboration between medical
doctors and SLPs aiming at providing better care be-
comes evident in incongruent diagnoses of physicians
and SLPs. Hence, only a very small portion of clinicians
treat multilingual children irrespective of their own diag-
nostic findings, and more than half of the surveyed clini-
cians, in defiance of the previous medical diagnosis of a
language disorder, found lack of language skills following
a comprehensive SLT assessment instead. On the one
hand, this may indicate a medical overdiagnosis and/or
on the other hand, an expression of confidence in SLT
differential diagnosis competences and assessment pro-
cedures in order to confirm, specify, or reject the medical
diagnosis of prescription as to an early time as possible.
The current findings rather confirm the latter, thus indi-
cating the notion of a collaborative model, as exchange
and transfer of knowledge between those who require this
information seems to occur. However, it remains unclear
whether this collaboration is incidental or intentional.
In agreement with the best practice recommendations
of the literature [15, 19, 27], most surveyed clinicians con-
firmed to use a variety and combination of diverse assess-
ment methods to obtain the most complete assessment
information, such as spontaneous speech samples in all of
the languages with diverse interlocutors, language-pro-
cessing measures, criterion-referenced measures, dy-
namic assessment procedures, and a full profile of the
child’s case history including an individual multilingual
profile. However, as the latter information is usually
sourced in interviews with parents and/or caregivers, cul-
tural and linguistic mismatches may challenge many cli-
nicians. The current results demonstrate and confirm the
challenges associated with serving a linguistically and cul-
turally heterogeneous population that requires a corre-
spondingly comprehensive expertise for a valid assess-
ment and consultative intervention. The common mis-
match between patient and clinician languages is evident
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DOI: 10.1159/000495565
as they do not reflect the variety of numerous migrant
languages, and SLT service offered in a migrant language
such as Turkish or Russian is extremely rare. Moreover,
they do not comply with the many diverse languages and
varieties spoken by immigrants and refugees from Syria,
Bulgaria, Romania, or the Maghreb countries that have
largely immigrated to Germany in the past years. As lan-
guage barriers impede assessment and intervention for
language competence is conducted via language itself, bi-
ased assessment and as a consequence inadequate inter-
vention are evident risk factors [28]. In addition, it is evi-
dent that applying comprehensive assessment measures,
which is in accordance with best practice [14, 19, 27],
takes more time compared to using procedures devel-
oped with monolingual children. On the basis of the ele-
ments provided, this requires a corresponding minimum
amount of time, estimated by the methods given as three
to five units (regularly 45 min per unit). In addition, the
clinician’s use of diverse assessment methods in combi-
nation applies fully with the recommended best practice.
Many respondents reported that they had received addi-
tional training in multilingualism, which underscores the
need to provide education courses already within initial
education.
The increased use of standardized assessments and
thus the use of material developed with a monolingual
mindset and/or applying normative data that has been
developed with monolingual German children is serious-
ly questionable, as this will increase construct, method,
and item bias and subsequently the risk of misdiagnoses
[21, 3]. An alternative interpretation of the use of stan-
dardized assessments by more than every second clini-
cian may be that it is done to complement the abovemen-
tioned measures following the identification of a lack of
language skills after a language disorder has already been
ruled out by the SLP’s thorough assessment. At the inter-
section of the health and educational systems, the SLP’s
objective then has changed from a clinical one to provid-
ing an estimate on successful school attendance in orien-
tation to the monolingual norm and placement into regu-
lar classroom instruction, even if SLPs in Germany for-
mally do not have authority to do so.
The current results show that indeed many of the sur-
veyed clinicians identify a lack of language skills instead of
an indication for therapy. It is noteworthy that this is more
often the case in districts with high child poverty. This
finding is concordant with those previous studies linking
SES to language development [29, 30]. Although a low SES
background does not necessarily lead to a language disor-
der, low SES children are more likely to demonstrate com-
prehension deficits leading to SLCN [31]. As SES impacts
well-being and subsequently health at multiple levels, SLT
practices seem to unofficially function as a support system
to family and neighborhood. As a result, in many cases the
respondents carry out parent training or counseling in-
stead of therapy and despite their command may even
keep multilingual children without language disorder on
their caseload. Possible motivation on the part of the clini-
cians to take measures of support irrespective of therapy
indication can also be deduced from the current findings.
Thus, a large proportion of respondents see a high risk of
discrimination and stigmatization of multilingual chil-
dren with migrant background. This is a legitimate con-
cern as it is in line with studies clearly demonstrating that
multilingual children with migrant background are more
likely to experience severe disadvantages at German
schools, for the education system in Germany is consid-
ered “deeply unequal, hierarchical and exclusive” [32, p.
93]. As the German education system, including kinder-
garten, has been claimed to fail to provide adequate lan-
guage training for children who speak native languages
other than German, the competencies of SLPs could play
a key role in early identification and planning of appropri-
ate actions for their improvement. SLPs are competent to
serve in both systems, health and education. Strategic col-
laboration with education providers as done in other
countries could contribute to solving this issue. However,
this requires a greater flexibility of the system and the legal
allowance to autonomously see children and derive diag-
noses independent of a medical doctor.
Conclusion
This study provides data on provision of SLT services
to multilingual children with a migration background in
Germany. Although the results of the study are based on
a regional survey of a limited number of clinicians and
hence cannot be generalized, they do suggest that there
are considerable differences between the referral reasons
and the SLPs’ diagnoses of these children’s difficulties.
The results highlight the need for collaborative models of
multiprofessional exchange and a concrete solution-fo-
cused approach to a population that requires support
from both health care and education. One approach may
be a change of legal allowance for SLPs to not only serve
in the health care but also in the educational system. In
this way they could make a contribution to support the
children. The demand for these qualified professionals is
high. Further, there is a considerable need to make the
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SLT Services for Multilingual Children
with Migration Background
125
Folia Phoniatr Logop 2019;71:116–126
DOI: 10.1159/000495565
profession more attractive for recruitment and retention
of future SLP professionals in Germany. Moreover, the
results highlight that multilingual children with and with-
out migrant background are put at a higher risk from a
lack of access to SLT provision and emphasize the risk of
a future lack of clinicians. The current findings point out
the need for a timely referral by medical doctors and – in
terms of content and time – a comprehensive differential
SLT diagnosis to avoid the risk of misdiagnoses in cultur-
ally and linguistically diverse children. These aims can be
most strongly advocated when SLT qualification pro-
grams account for competencies in this area and adapt
their curricula and practical training by including knowl-
edge and different strategies for action in culturally and
linguistically diverse settings. Future research on lan-
guage disorders in multilingual children needs to account
for the relationship between migration and SES.
Acknowledgments
The work was supported by the Hochschule Bremen Fund for
Research and Development. The author would like to thank all
clinicians who took part in this study.
Statement of Ethics
The study was approved on February 16, 2016 by the review
board of ethics of the Hochschule Bremen. Informed consent was
obtained.
Disclosure Statement
The research was funded by a grant of the Hochschule Bremen
Fund for Research and Development. There are no other declara-
tions.
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