Language Assessment for Bilingual Children
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As our caseloads get more diverse, more SLPs are tackling the challenge of diagnosing and qualifying children who are bilingual, multilingual, or are English learners. There are so many factors to take into account—what languages are in the mix, how long the child has been exposed to English, which language is dominant, the validity (or lack thereof) of test instruments normed on monolingual speakers… not to mention the issue of finding and using interpreters and that perpetual problem: TIME.
The following twelve research reviews, covering articles published between 2013 and 2019, chip away at some of those big questions. The first review discusses current practices in bilingual assessment among school-based SLPs. After that, two reviews tackle Spanish morphosyntactic development (typical and disordered). Finally, six reviews discuss specific assessment methods, including two reviews on aspects of language sample analysis and seven relating to standardized assessments. A lot of the information relates specifically to children who speak Spanish as a primary or a home language, but many concepts will be relevant to children from different language backgrounds. You’ll come away with a whole menu of assessment options, including:
Parent questionnaires combined with parts of (English!) standardized tests
Alternate scoring/administration of vocabulary tests
A standardized assessment designed for bilingual children
That’s great, but what should I actually DO? It can be a little confusing to take all this information on board and try to synthesize it into a game plan for your next assessment. We can suggest a couple ways to approach and use this research. First, read for the big picture: what types of assessments tasks (in general) are useful—and not—for identifying language disorders in a young bilingual child? Second, picture these studies as a big toolbox full of a bunch of slightly different screwdrivers, or wrenches, or something. You can’t rely on just one, because you’re going to encounter lots of different situations calling for just the right fit. In language testing, you’ll have various ages, language backgrounds, and other factors to take into account when you’re matching an assessment process to a kid. As you read and learn, here and elsewhere, take some notes, make yourself a chart, or keep printouts on file. Then, when you get your next tricky assessment, look back and see what assessment battery has good diagnostic accuracy for kids similar to yours.
Now, are there still gaps in our knowledge? Um, yeah. Lots of research waiting to be done. There will continue to be odd cases (bolts, possibly, in the tool analogy?) where you have to rig up a solution based on your clinical expertise and knowledge of the fundamentals. But every time we can approach an assessment with the best, most current knowledge in hand, we chip away at the systemic problem of under- and over-identification of language disorders in our young bilingual friends.
Bilingual language assessment trends in schools
This survey study examined the current practices of school-based SLPs in bilingual language assessment, finding general improvement over the last decade when comparing their results to previous studies (yay us!). SLPs today are more often combining formal with informal techniques, such as standardized testing along with language sample analysis and interviews. They are also “becoming increasingly aware of the need to administer assessments in the student’s native language” (77% of SLPs).
Authors mention that there remains some over-reliance upon standardized tests in the diagnostic process, which is particularly problematic for bilingual students because of cultural and linguistic biases inherent in translated tests. They emphasize that SLPs should be collecting language samples in both languages, and hint at resources to make this easier (e.g. did you know that you can pay SALT to transcribe language samples for you, in English and Spanish?). They also summarize options for alternative assessment techniques, such as dynamic assessment, to “…identify what a child is able to learn rather than the exposure a child has had…”.
The authors examined SLPs’ barriers to providing comprehensive bilingual assessments, with a primary one being time. Authors suggest, “SLPs may need to consult with their administrators to identify strategies to alleviate the time and resource constraints in order to serve the bilingual population.”
Arias, G., & and Friberg, J. (2016). Bilingual Language Assessment: Contemporary Versus Recommended Practice in American Schools. Language, Speech, and Hearing Services in Schools. doi: 10.1044/2016_LSHSS-15-0090.
How do bilingual children acquire Spanish morphemes?
We all know about Brown’s stages of morphosyntax development for English-speaking children, but what do you know about grammatical morpheme acquisition in bilingual children? Because it’s important that we compare bilinguals’ language skills to those of other bilinguals, this paper provides preliminary evidence for the relative difficulty of Spanish morpheme acquisition for typically developing Spanish–English speaking children.
The authors grouped the Spanish morphemes* into three sets (shown below) from least difficult to most difficult. Typically developing Spanish–English bilingual children, ages 4 to 7.5, generally acquired these morpheme sets in the same order, regardless of whether Spanish or English was their dominant language. In other words, there were similarities for all bilingual children in the study as to which morphemes were easier and which were more difficult for them to acquire.
The children used the morphemes in Set 1 most accurately. Spanish-dominant children mastered Set 2 at an MLUw of 7.00–7.99, but English-dominant children in the study did not reach that same level of accuracy. Neither group fully acquired Set 3 morphemes by age 7.5.
It’s important to note that this study established norms based on elicitation and sentence repetition tasks, rather than spontaneous language samples; however, MLUw data from the children’s narrative samples were used to calculate the morpheme accuracies reported in the paper.
The authors remind us that MLUw is a better predictor of Spanish grammatical morpheme accuracy than age, which is similar to what we know about morpheme acquisition in monolingual English children. Since more research is needed in this area, we ultimately need to continue to assess bilingual children in both languages and consider the child’s dominant language. We must assess both MLUw and grammatical morpheme use, comparing that data with appropriate developmental norms, to provide a comprehensive summary of the child’s morphosyntactic skills.
*If you need a refresher on Spanish morphemes, check out the “Morphosyntactic Development in Monolingual Spanish” section here.
Baron, A., Bedore, L. M., Peña, E. D., Lovgren-Uribe, S. D., López, A. A., & Villagran, E. (2018). Production of Spanish Grammatical Forms in U.S. Bilingual Children. American Journal of Speech–Language Pathology. doi:10.1044/2018_AJSLP-17-0074
Error patterns of monolingual Spanish speakers with language disorder
Historically, studies of language disorder and grammatical error patterns have been primarily done on English-speaking children. For Spanish-speaking children, most recent studies have been mostly on bilingual Spanish–English speakers, who may have different error patterns than monolingual Spanish speakers. This study describes the error patterns of 49 monolingual Spanish-speaking children with language disorders (traditional ‘SLI’—so these children all had IQs > 85 and no other developmental disorders). The researchers found that:
articles were most frequently in error; in Spanish, this is “el” or “la” ( = the), “un” (= a)
prepositions were also found to be difficult for these children; in Spanish, this is “por” (= through, for), “de” (= of)
Most important is recognition that this pattern is different than what is observed in English-speaking children with language disorders. The authors state: “In particular, auxiliaries are less sensitive to SLI in Spanish than in English. In contrast, articles, clitics, prepositions, and connector words are more vulnerable in Spanish than in English.” Thus, error patterns of language disorder are unique to the language the child speaks. When trying to differentiate Spanish-speaking students with language disorder from those without, the authors found the strongest predictors were utterance-level grammaticality and excessive word or morphological omissions.
Jackson-Maldonado, D., & Maldonado, R. (2017). Grammaticality Differences Between Spanish-speaking Children with Specific Language Impairment and Their Typically Developing Peers. International Journal of Language and Communication Disorders. doi: 10.1111/1460-6984.12312
LSA for diagnosing language disorder in Spanish–English bilingual children
This study looked at language samples from 40 Spanish-English bilingual children—20 with developmental language disorder and 20 with typical language. Samples were elicited in Spanish (L1) using wordless picture books. The children repeated a story read to them (retelling) and generated a story on their own (storytelling). Samples were transcribed with SALT and CLAN and coded for: “…lexical diversity (D)*, grammaticality (grammatical errors per communication unit [GE/CU]), sentence length (mean length of utterance in words [MLUw]), and sentence complexity (subordination index [SI]).” Key findings are in the chart below:
The results suggest that LSA by itself was fairly accurate at diagnosing language disorder in this population, and that different elicitation methods bring out different skills. However, note that this study included only a small sample of 4- to 5-year-old Spanish-English bilinguals whose language was sampled in Spanish. These results may not apply to other age groups, or to monolingual Spanish- or English-speaking children with language disorder. Overall, this study reiterates that LSA is an important part of a language assessment for bilingual children.
*D is a measure of lexical diversity computed by CLAN that is less influenced by sample size than measures like type token ratio (TTR). Remember, CLAN is free! All other measures were computed by SALT.
Kapantzoglou, M., Fergadiotis, G., & Restrepo, M. A. (2017). Language Sample Analysis and Elicitation Technique Effects in Bilingual Children With and Without Language Impairment. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2017_JSLHR-L-16-0335.
Identifying “disorder within diversity”
This month, ASHA’s Language, Speech, and Hearing Services in Schools journal put out a (free!) clinical forum on the concept of “disorder within diversity.” The forum includes an introduction, where you can read about the usefulness of moving away from “difference vs. disorder,” and five related research articles. Here we review one of the articles, and others can be found here, here, and here.
Do you like your grammatical morphemes accurate, diverse, or productive?
So, you’re an awesome clinician who is eliciting and analyzing a language sample from a bilingual preschooler. High five for you! You want to capture some data about their grammar skills. What exactly do you measure?
The authors of this study suggest that, rather than counting up how accurate the child’s use of tense and agreement markers is (so, finding the percentage of accurate uses out of total obligatory contexts), you instead focus on the diversity and productivity of tense/agreement markers. The morphemes we’re concerned about are:
third person singular –s
past tense –ed
copula BE (am, are, is, was, were)
auxiliary DO (do, does, did)
auxiliary BE (am, are, is, was, were).*
Notice there are five morphemes and 15 total forms here; that’ll be important in a second. These morphemes are clinical markers for language disorders in English.
So what are diversity and productivity, and how do you measure them? Enter tense marker total and TAP score. We’ll give the basic gist of both, but the specifics for calculating them came from Hadley & Short (2005).
Diversity (tense marker total): How many of those 15 forms from earlier did the child use in the language sample?
Productivity (tense/agreement productivity, or TAP score): How many different ways did the child uses those five morphemes? Up to five points allowed per morpheme, for a max of 25.
The authors found that, for a group of 4-year-old Spanish–English bilingual children, tense marker total and TAP scores:
Were correlated with MLU(words) and NDW (number of different words), valid LSA measures for this population
Changed over the course of a school year
Looked different for children with and without parent-reported language concerns
The article provides group means (typical language vs. language concerns) for both measures, but not true normative or diagnostic data, so you can’t use tense marker totals or TAP scores to directly diagnose a language disorder at this point. However, consider using them as criterion-based measures to describe tense and agreement skills, identify morphemes to focus on in therapy, and monitor growth.
*If you’re having one of those days and can’t remember the difference between a copula and auxiliary—no sweat. A copula is the only verb in a clause (like is was, there), but auxiliaries are those “helping verbs” that are linked up with another verb (like are was with linked, there).
Potapova, I., Kelly, S., Combiths, P. N., & Pruitt-Lord, S. L. (2018). Evaluating English Morpheme Accuracy, Diversity, and Productivity Measures in Language Samples of Developing Bilinguals. Language, Speech, and Hearing Services in Schools, 49(2), 260–276.
Diagnosing #devlangdis in English learners
Accurately identify ELL children with developmental language disorder
DANGER! Potential Hazards!
“Waiting and seeing” so long you lose the benefits of early intervention
Over-referral of typical English learners to Special Ed
Fortunately, there are a decent number of assessments around for Spanish-English bilinguals, but for the one million kids out there with less common home languages? Yeah, pretty much nothing. Until the day we have a Tagalog–English CELF, we have to improvise.
These researchers wondered whether they could discriminate typical vs. language-impaired ELL children based on a handful of English-only assessments and a parent questionnaire, which asked about development of the L1 and asked parents to compare their child to other kids they know. The kids were around kindergarten age, from immigrant families with a diverse assortment of home languages, and hadn’t had regular English exposure before age three.
They were able to reach over 90% diagnostic accuracy with a combination of their parent questionnaire (the most important factor by far), tests of nonword repetition and tense morphology (from the CTOPP and TEGI, respectively, which together made a smaller but still important contribution), and a narrative task (the ENNI, which was the least important factor). They also gave the PPVT, but that wasn’t helpful. This makes sense, because we already know it’s not good at diagnosing DLD in anybody.
Bottom Line: You can differentiate young ELL children with language disorder from their typically-developing ELL peers IF…
You get good input from the parent on L1 development
You test the skills that are known to be hard for ALL kids with DLD (like nonword repetition and tense morphology). Don’t rely on tests of single-word vocabulary.
You compare ELL kids to one another, not the monolingual norming sample of most assessments. See if ELL norms are available for the tests you use!
Paradis, J., Schneider, P., & Sorenson, T. (2013). Discriminating Children with Language Impairment Among English-Language Learners from Diverse First-Language Backgrounds. Journal of Speech, Language, and Hearing Research. doi: 10.1044/1092-4388(2012/12-0050).
Diagnosing DLD when you don’t speak a child’s first language
We know that it’s best to assess children in their first languages. But, we simply don’t have access to measures or interpreters for all of the world’s languages. What’s a monolingual SLP to do?
New research supports what we’ve discussed previously: that by using parent questionnaires and measures of language processing, we can accurately diagnose language disorders in English language learners using only English measures. Li’el et al. recruited a sample of bilingual and monolingual Australian English-speaking 5- to 6-year-old children with and without developmental language disorder (DLD). “Bilingual” was defined as hearing English less than half the time at home. Parents completed a questionnaire and children completed the CTOPP nonword repetition and CELF-P2 recalling sentences subtests.
The researchers found that the parent questionnaire alone had the highest sensitivity and specificity (accuracy at ruling in and ruling out DLD). However, all of the assessments in combination still had good diagnostic accuracy, and it’s not a good idea to diagnose a child with only one test, so the authors recommend using more than one measure.
Overall, this study adds to evidence that by interviewing parents and using language processing tasks, we can do a pretty good job teasing apart a lack of English exposure from an underlying language disorder even if we can’t assess in a child’s first language.
Li’el, N., Williams, C. & Kane, R. (2018). Identifying Developmental Language Disorder in Bilingual Children from Diverse Linguistic Backgrounds. International Journal of Speech-Language Pathology. doi: 10.1080/17549507.2018.1513073
Administering vocabulary tests to bilingual children
Assessing bilingual children’s vocabulary skills is challenging because they may know different words across their languages. One method to address this problem is conceptual scoring of vocab tests, in which the child gets credit for knowing the word in at least one language. For example, if the child misses the English word shoe but recalls the Spanish word zapato, he gets the point for that item.
One way to go about getting conceptual scores is to test the child in one language and switch to another to prompt any words the child doesn’t know. However, the child’s ability to switch between languages may be affected by language dominance or context, possibly affecting performance. Another way is to test the two languages separately, and then complete conceptual scoring by looking at the items across the tests. This method takes longer, but doesn’t require the child to switch between languages.
This study examined the effects of different test administration methods on conceptual vocabulary scores. Researchers administered the English and Spanish-English Bilingual versions of the Expressive One-Word Picture Vocabulary Test - Third Edition (EOWPVT-3 and EOWPVT-3 SBE) to elementary-age bilingual children—38 with developmental language disorder** (DLD) and 209 with typical language. They compared results from one session where both languages were prompted vs. separate sessions for each language (i.e., giving the EOWPVT-3 in English only, and the EOWPVT-3 SBE in Spanish only, and accepting correct answers on either test when scoring).* Children scored higher when conceptual scoring was used across independent administrations in each language than when they were prompted to switch languages within a single test administration. This suggests that switching between languages may negatively affect children’s performance, possibly causing us to underestimate their vocabulary skills.
But, wait! Who has time to administer basically the same test twice? The authors note that prompting only the missed items in the second language at the end of the test rather than switching back and forth with every item might be a good compromise, but that idea isn’t addressed by this study.
The authors also looked at whether using conceptual scoring resulted in accurate identification of children with DLD. No matter how the EOWPVT-3 was scored, it did not meet minimum standards for diagnosing DLD (i.e., sensitivity and specificity above 80%). This reinforces previous research (e.g., here and here) showing that vocabulary tests should be used only to describe children’s vocabulary abilities, not to diagnose DLD.
*See the full article for specifics on the different scoring methods. It gets a little tricky, since there are some items that shouldn’t be scored if you’re using the bilingual test norms.
**Note: The children in this study were those with Specific Language Impairment (SLI), which is a child with Developmental Language Disorder (DLD) and normal nonverbal intelligence. We use DLD throughout our website for consistency purposes (read more here).
Anaya, J. B., Peña, E. D., & Bedore, L. M. (2017). Conceptual Scoring and Classification Accuracy of Vocabulary Testing in Bilingual Children. Language, Speech, and Hearing Services in Schools. doi: 10.1044/2017_LSHSS-16-0081.
Language of school and SES matter in standardized testing of bilinguals
Assessing children from diverse language backgrounds can be a challenge, but at least for Spanish speakers, SLPs have a decent array of resources available—including a growing number of standardized tests. The CELF–4S is one of these, designed to diagnose language disorders in Spanish speakers (mono- or bilingual) from 5–21 years old. It’s not just a Spanish translation of the English CELF, but is written specifically for speakers of Spanish. Great, right?
The problem is that the norming sample for this test was somewhat smaller than what’s recommended, and so the norms in the test manual may not be valid for all groups. Previously, there have been disagreements between the test creators and other researchers about whether you need separate norms for monolingual and bilingual speakers (in the test manual, they’re together).
This study focused on children from 5–7 years old with multiple risk factors for underperformance on standardized language tests. These included low SES(low-income family and parents with lower levels of education) and attending an English-only school, which favors English to the detriment of the home language. The researchers gave the CELF–4S to a huge group (656) of these kids, a lot more per age bracket than the test was originally normed on. The average Core Language Score was 83.57—more than one standard deviation below the mean, which is given in the manual as the cut-off score for identifying a language disorder. In Table 3, you can see how the results break down by subtest and age group. And, yes. You read that right. Given the published test norms, over half of these kids would appear to have DLD.
Wow. This is clearly not okay. So what do we do?
It looks like we need separate test norms for low-SES children in English schools. The authors used a subset of the original sample (still large at 299, 28 of whom had been found to have a language disorder via multiple methods of assessment) to look into the test’s diagnostic accuracy. That cut-off score of 85? Yeah, it resulted in so many false positives (specificity of only 65%) that it wasn’t clinically useful. The researchers computed an adjusted cut-off score of 78 for this group, which has acceptable diagnostic sensitivity and specificity (85% and 80%, respectively).
The big takeaway is this: Use the CELF–4S very cautiously. Understand the limitations of the normative sample used to standardize the test. If you are working with kids matching the profile of this paper’s sample (5-7 years old, low-SES/maternal education, and in English-only schools), keep that adjusted cut-off score of 78 in mind. And above all, remember that standardized testing alone is not a good way to assess young English learners.
Barragan, B., Castilla-Earls, A., Martinez-Nieto, L., Restrepo, M. A., & Gray, S. (2018). Performance of Low-Income Dual Language Learners Attending English-Only Schools on the Clinical Evaluation of Language Fundamentals–Fourth Edition, Spanish. Language, Speech, and Hearing Services in Schools. doi: 10.1044/2017_LSHSS-17-0013.
Assessing language with diverse preschoolers? Go for dynamic assessment
Making the right call when assessing language skills of children with cultural or language backgrounds that don’t match our own is hard. Using our go-to assessment methods, we risk labeling normal language variation as signs of a disorder. Standardized test norms may over-identify children from non-mainstream language backgrounds as having language impairment.
Enter dynamic assessment, which involves testing a child, providing teaching and support, and then retesting to see what the child can do with help. In a new study, Henderson et al. used dynamic assessment to assess language skills of Navajo preschoolers with narrative retell tasks from the Predictive Early Assessment of Reading and Language (PEARL, from the same acronym aficionados that brought us the DYMOND).
Dynamic assessment takes longer than static (one-time) assessment. The PEARL accounts for this—you give the pretest, look at the score, and then administer the teaching and retest only if it’s below a cutoff. Henderson et al. found that the reported cutoff score for the PEARL pretest didn’t work well for Navajo children; sensitivity and specificity were better with a cutoff score of 7 rather than 9. Looking at the whole test, scores on the retest (following teaching) were even better at diagnosing children, and examiners’ “modifiability” ratings (how the child responded to teaching) diagnosed children with 100% accuracy. These findings suggest that the PEARL is a valid test for assessing language in children from non-mainstream language or cultural backgrounds.
Henderson, D. E., Restrepo, M. A., & Aiken, L. S. (2018). Dynamic Assessment of Narratives Among Navajo Preschoolers. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2018_JSLHR-L-17-0313.
Spanish and English and narratives, oh my!
We know that narrative comprehension and production skills are important for classroom success, but it can be difficult to interpret narrative assessment results for our bilingual clients. Gibson et al. compared the performance of Spanish–English bilingual children with and without developmental language disorder* (DLD) in kindergarten and first grade on the Test of Narrative Language (TNL; administered in English). They found that:
Across all ages and tasks, children with typical development performed better than children with DLD.
On the overall TNL, kindergarteners with DLD had lower receptive than expressive scores, while typical children did not. This “gap” went away in first grade.
This suggests that narrative tasks are useful for diagnosing DLD in bilingual children, and that higher receptive than expressive skills are a potential red flag. But, an important note: the authors state that the TNL does not have enough bilingual children in its norms to diagnose DLD in this population. And, sure enough, the typical children in their study scored lower than the mean score on the TNL in kindergarten. We can still use the TNL or similar narrative tasks to describe the language abilities of bilingual children, though.
So we know that assessing bilingual children’s narratives is important, but where do we go from there? Here’s one idea: Miller et al. taught four school-age Spanish–English bilingual children with DLD to tell more-complete narratives using the Story Grammar Marker. If you’ve never seen one of these, it’s…kind of like an arts and crafts project? Each little doodad represents a story grammar element (e.g., setting, characters, problem). During one-on-one treatment sessions (three half hours per week, conducted in English), researchers taught story grammar elements, modeled stories, supported children’s retells, and encouraged independent retells. All children showed improvement on narrative organization, but improvements on measures of retell length, vocabulary, and grammar were mixed. This is a small study, but it’s the first to look at story grammar intervention in this population, and the initial results are promising.
*Note: The children in this study were those with Primary, or Specific, Language Impairment (PLI/SLI), which refers to children with Developmental Language Disorder (DLD) and normal nonverbal intelligence. We use DLD throughout our website for consistency purposes (read more here).
Gibson, T. A., Peña, E. D., & Bedore, L. M. (2018). The Receptive–Expressive Gap in English Narratives of Spanish–English Bilingual Children With and Without Language Impairment. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2018_JSLHR-L-16-0432
Miller, R. D., Correa, V. I., & Katsiyannis, A. (2018). Effects of a Story Grammar Intervention with Repeated Retells for English Learners with Language Impairments. Communication Disorders Quarterly. doi: 10.1177/1525740117751897
A one–two punch for assessing young Spanish–English learners
Do you serve pre-K or kindergarten-aged kids? Are some/lots/all of them from Hispanic backgrounds and learning Spanish AND English? Mandatory reading right here, friends!
So—a major issue for young, dual-language learners? Appropriate language assessments. We talk about it a lot (plus here, here, here, and here, to name a few). In this new study, the authors compared a handful of assessments to see which could most accurately classify 4- and 5-year-olds (all Mexican–American and dual-language learners) as having typical vs. disordered language.
The single measure with the best diagnostic accuracy was two subtests of the Bilingual English-Spanish Assessment (BESA)—Morphosyntax and Semantics (the third subtest is phonology, which they didn’t use here). But to get even more accurate? Like, sensitivity of 100% and specificity of about 93%? Add in a story retell task (they used Frog, Where Are You?). Sample both Spanish and English, and take the better MLUw of the two. This BESA + MLU assessment battery outperformed other options in the mix (English and Spanish CELF-P2, plus a composite of the two, a parent interview, and a dynamic vocab assessment).
Not familiar with the BESA? It’s a newer test, designed—as the name implies—specifically for children who are bilingual, with different versions (not translated) of subtests in each language. If you give a subtest in both languages, you use the one with the highest score. And before you ask—yes, the test authors believe that monolingual SLPs can administer the BESA, given preparation and a trained assistant.
Now, the researchers here don’t include specific cut scores to work with on these assessments, but you can look at Table 2 in the paper and see the score ranges for the typical vs. disordered language groups. They also note that an MLUw of 4 or less can be a red flag for this group.
The major issue with this study, affecting our ability to generalize what it tells us, is that the sample size was really small—just 30 kids total. So, take these new results on board, but don’t override all that other smart stuff you know about assessing dual-language learners (see our links above for some refreshers if needed). And keep an eye out for more diagnostic studies down the road—you know we’ll point them out when they come!
Lazewnik, R., Creaghead, N. A., Smith, A. B., Prendeville, J.-A., Raisor-Becker, L., & Silbert, N. (2018). Identifiers of Language Impairment for Spanish-English Dual Language Learners. Language, Speech, and Hearing Services in Schools. doi: 10.1044/2018_LSHSS-17-0046
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