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Bilingual Assessment
in 475: Research,
Needs, and Resources
Definitions
• L1: “Language 1.” Sometimes called the heritage language or the native language. The
first language a student learns.
• L2: “Language 2”. Sometimes called the second language or the non-native language.
• Sequential bilingual: learners learned L1 first and then L2.
• Simultaneous bilingual: those who grow up immersed in both languages from birth or a
very early age.
• Transfer: Transfer is when an error is made in the emergent (L2) as a result of the
native/first language (L1) influence. Transfer is also sometimes called language mixing,
code-mixing or interference. Transfer can be apparent in morphosyntax, semantics, and
speech sound development.
Why is Bilingual Assessment Important?
• “Distinguishing between people who have a disorder and people
who do not is one of the most fundamental tasks in clinical
practice. The problem is exacerbated by the heterogeneous
outcomes of bilingualism and superficial similarity observed
between the linguistic performance of children with DLD and
bilinguals, especially if they are assessed in their weaker language
at the time of assessment). Often, the weaker language is the
heritage language since typically exposure and use of that
language decline as the societal language becomes more
robust.”(Dollaghan & Horner, 2011).
Hierarchy of Best Practice
Standardized bilingual or L1
assessment with bilingual SLP
Standardized assessment with an SLP
and a trained interpreter. Scores reported
with caution and triangulated with other
data.
Dynamic assessment. May include content analysis of
standardized assessments without use of scores,
language/speech sample analysis, parent/teacher
questionnaires. Should include research on a native
language’s morphosyntax and phonetic inventory .
Challenges
• Research and providers cannot
keep up with the need.
• Few tests are truly bilingual.
Monolingual tests lack the sensitivity
and specificity which can result in the
over or under diagnosis of language
delays or disorders in bilingual
children.
• Monolingual norms are not
representative of bilingual populations
and thus lack validity.
• Dialect of a language impacts
articulation and pitch. i.e. Ecuadorian
vs Puerto Rican Spanish.
USD 475 Stats
7% of the
district
population is
ELL
Population
Age Range
Elementary has the
highest population
of ELL students
Most Common Languages in the District
Spanish
Pohnpeian, Kosrean,
Paluan (each)
Samoan, Tagolog,
German (each)
Assessments We Currently
Have
Based on the test list from the IRC
Name Area Ages Summary #
Preschool Language
Scale 5 Spanish
Receptive and
Expressive
Language
0-
7;11
“Normed on 1150 children in the U.S. and Puerto Rico. Can identify
language delays/disorders in Spanish speakers or bilingual speakers.
Ordered differently than the PLS-5 (English): First all receptive
(Spanish, English), then all expressive (Spanish, English).” (Source:
Bilinguistics)
1
Expressive One Word
Picture Vocabulary,
Spanish/Bilingual Ed.
Expressive
Language
2;0-
70;0
“Assesses expressive single word vocabulary. For bilingual students
can hint towards need for dynamic intervention where concepts are
taught prior to use of concepts in intervention session.” (Source:
Bilinguistics)
2
Receptive One Word
Picture Vocabulary
Test Spanish/Bilingual
Ed.
Receptive
Language
2;0-
70;0
“Assess receptive single word vocabulary. For bilingual students can
hint towards need for dynamic intervention where concepts are taught
prior to use of concepts in intervention session.” (Source: Bilinguistics)
2
Clinical Evaluation of
Language
Fundamentals 4-
Spanish Ed.
Receptive and
Expressive
Language
5-21 Subtest scores are divided into areas of need. Vocabulary score is a
good indicator of language ability for bilingual students, especially if
taken as part of a total vocabulary. (Source: Bilinguistics)
2
Goldman Fristoe Test
of Articulation-3
Spanish
Articulation “The GFTA-3 Spanish is not a translation of the English edition. While
much of the art is shared across the English and Spanish editions,
scoring is based on phoneme production of words in Spanish.”
(Source: Pearson)
1
Norm-Referenced Assessments
to Consider for Purchase
Based on “Common Communication Measures” from Bilinguistics
Name and Price Area Ages Summary
The Bilingual Spanish
English Assessment
(BESA)
$550
All major
communicati
on areas
4;0-
6;11
“The BESA is a language evaluation to use with young
Spanish/English bilingual children. It has two questionnaires and
divides the testing area into three subtests (Semantics, Morphosyntax,
and Phonology). There is an additional Pragmatic Language Area that
is not scored. Components can be used independently or as an
assessment battery.” (Source: Bilinguistics)
Bilingual Articulation and
Phonology Assessment
(BAPA)
$45 unlimited
administrations.
Articulation
and
phonology
3;0-
10;11
“The BAPA is an iPad Test for both monolingual and bilingual
children. Both languages can be tested, responses are marked and
tabulated as you progress. The results, scores, and tables are created
immediately upon completion. Sound prompts, recording productions,
and repetitions are all possible.” (Source: Bilinguistics)
Norm-Referenced Assessments to Consider
for Purchase
What else is available: Questionnaires
• “Intelligibility in Context Scale for Parents and Teachers.” Available
in multiple languages. Link is on Schoology.
• We have the ASQ and the DIAL-4 parent questionnaires available in
Spanish.
• The Speech Participation and Activity Assessment of Children (SPAA-
C). Link is on Schoology.
What else is available: Nonstandard
• SALT software and Narrative Scoring scheme:
https://www.saltsoftware.com/media/wysiwyg/codeaids/NSS_Scoring_Guide.pdf
• Language sampling considered the “gold standard”.
• English/Spanish Comprehension questions for the story “Frog Where are You?”
file:///C:/Users/bridgetmooney/Downloads/Frog-Where-Are-You-Comprehension-Questions-Eng-and-
Spn.pdf
• Rojas and Iglesias (2009) recommended three specific measures for use with Spanish–English bilingual
speakers: mean length of utterance in words (MLUW), number of different words (NDW), and words per
minute (WPM). MLUW indexes syntactic skill, NDW measures lexical diversity, and WPM indicates overall
verbal fluency
What else is available: Nonstandard
• Spanish Phonology Test. 100 word phonology test in Spanish and
English. Supplemental cluster lists and a screener are also available in
both languages and can be found at:
https://phonodevelopment.sites.olt.ubc.ca/practice-units/spanish/
• Bilingual Communication Assessment Resource Book.
• Other ideas?
Questions for you: What do we need?
• What languages?
Tagalog. Puerto Rican Spanish Pohnpeain
• What age groups?
About 3rd grade.
• What areas of communication?
BVAP
• How often have you utilized parent or teacher questionnaires as part of bilingual assessment?
• How often is your ELL teacher in the building? Are you able to utilize them as a resource when testing?
What other support would help?
• CEUs?
• Aide/Interpreter training?
• More conversations/training with or from the ELL department?
References
• Bedore, L.M., Peña, E.D., Gilliam, R.B. & Ho, T.S. (2010). Language sample measures and language ability
in Spanish-English bilingual kindergarteners.
• Brice, A.E., & Brice, R.G. (2007). A tale of two languages. ASHA Leader. 12 (13), 14-39.
• Dollaghan, C. A. & Horner, E. A. (2011). Bilingual language assessment: A meta-analysis of diagnostic
accuracy. J Speech Lang Hear Res, 54(4), 1077-1088. doi: 10.1044/1092- 4388(2010/10-0093).
• Ebert, K. D., & Pham, G. (2017). Synthesizing Information From Language Samples and Standardized Tests
in School-Age Bilingual Assessment. Language, speech, and hearing services in schools, 48(1), 42–55.
https://doi.org/10.1044/2016_LSHSS-16-0007
• Goldstein, B., Pena, E.D., Kiran, S., Mahendra, Gabrielsa, S.C. (2017). 2 Languages 2 Worlds. Retrieved
from: https://2languages2worlds.wordpress.com/
• Grob, A., Keller, K., & Troesch, L.M. (2015). A large receptive–expressive gap in bilingual children.
Frontiers in Psychology. 6: 1284 Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548084/.
• Guo L-Y, Eisenberg S. Sample Length Affects the Reliability of Language Sample Measures in 3-Year-Olds:
Evidence From Parent-Elicited Conversational Samples. Language, Speech, and Hearing Services in Schools.
2015;46(2):141-153. doi:10.1044/2015_LSHSS-14- 0052.
References cont.
• Hammer, C. S., Komaroff, E., Rodriguez, B. L., Lopez, L. M., Scarpino, S. E., & Goldstein, B. (2012). Predicting
Spanish–English bilingual children’s language abilities. J Speech Lang Hear Res, 55(5), 1251-1264. doi:
10.1044/1092-4388(2012/11-0016).
• Heilmann, J., Nockerts, A., & Miller, J. F. (2010). Language Sampling: Does the Length of the Transcript Matter?.
Lang Speech Hear Serv Sch, 41(4), 393-404. doi: 10.1044/0161-1461(2009/09-0023).
• Kritikos, E.P. (2003). Speech-Language Pathologists' beliefs about language assessment of bilingual/bicultural
individuals. American Journal of Speech-Language Pathology. 12, 73-91. doi:10.1044/1058-0360(2003/054).
• Levey, S. & Sola, J. (2013). Speech-language pathology students’ awareness of language differences versus language
disorders. Contemporary Issues in Communication Sciences and Disorders, 40, 8-14. Retrieved from:
http://www.asha.org/uploadedFiles/ASHA/Publications/cicsd/2013S-Speech-Language-Pathology-Students-
Awareness.pdf.
• National Center for Education Statistics (2016). English language learners in public schools. NCES. Retrieved from:
http://nces.ed.gov/programs/coe/indicator_cgf.asp.
• Patterson, J. L. (1998). Expressive vocabulary development and word combinations of Spanish-English bilingual
toddlers. Am J Speech Lang Pathol, 7(4), 46-56. doi: 10.1044/1058- 0360.0704.46.
• Peña, E. D., Gillam, R. B., Bedore, L. M., & Bohman, T. M. (2011). Risk for poor performance on a language
screening measure for bilingual preschoolers and kindergarteners. Am J Speech Lang Pathol, 20(4), 302-314. doi:
10.1044/1058-0360(2011/10-0020).
• Rose, K., Armon-Lotem, S., & Altman, C. (2022). Profiling Bilingual Children: Using Monolingual Assessment to
Inform Diagnosis. Language, speech, and hearing services in schools, 53(2), 494–510.
https://doi.org/10.1044/2021_LSHSS-21-00099
How ELL Serves our Students
•Push-in and pull-out services are offered to support
academics and English language development
•ELL aides act as verbal interpreters and written
translators for students and families at IEPs,
conferences, and throughout the school day.
•ELL teachers educate staff on native language and
assist with navigating cultural differences.
• **Please note, the ______ (test name) is not normed on bilingual speakers and does not take into account
differences in non-American dialects, or customs/cultural expectations that may influence a child’s
responses. In these scenarios, standardized assessments may be administered dynamically. Thus standard
scores should be taken with caution and understood in that context. They do not represent a complete
picture of ______ (student’s name) abilities. A further content analysis of developmental skills is included
below**

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Bilingual Assessment Discussion.pptx

  • 1. Bilingual Assessment in 475: Research, Needs, and Resources
  • 2. Definitions • L1: “Language 1.” Sometimes called the heritage language or the native language. The first language a student learns. • L2: “Language 2”. Sometimes called the second language or the non-native language. • Sequential bilingual: learners learned L1 first and then L2. • Simultaneous bilingual: those who grow up immersed in both languages from birth or a very early age. • Transfer: Transfer is when an error is made in the emergent (L2) as a result of the native/first language (L1) influence. Transfer is also sometimes called language mixing, code-mixing or interference. Transfer can be apparent in morphosyntax, semantics, and speech sound development.
  • 3.
  • 4. Why is Bilingual Assessment Important? • “Distinguishing between people who have a disorder and people who do not is one of the most fundamental tasks in clinical practice. The problem is exacerbated by the heterogeneous outcomes of bilingualism and superficial similarity observed between the linguistic performance of children with DLD and bilinguals, especially if they are assessed in their weaker language at the time of assessment). Often, the weaker language is the heritage language since typically exposure and use of that language decline as the societal language becomes more robust.”(Dollaghan & Horner, 2011).
  • 5. Hierarchy of Best Practice Standardized bilingual or L1 assessment with bilingual SLP Standardized assessment with an SLP and a trained interpreter. Scores reported with caution and triangulated with other data. Dynamic assessment. May include content analysis of standardized assessments without use of scores, language/speech sample analysis, parent/teacher questionnaires. Should include research on a native language’s morphosyntax and phonetic inventory .
  • 6. Challenges • Research and providers cannot keep up with the need. • Few tests are truly bilingual. Monolingual tests lack the sensitivity and specificity which can result in the over or under diagnosis of language delays or disorders in bilingual children. • Monolingual norms are not representative of bilingual populations and thus lack validity. • Dialect of a language impacts articulation and pitch. i.e. Ecuadorian vs Puerto Rican Spanish.
  • 7. USD 475 Stats 7% of the district population is ELL Population Age Range Elementary has the highest population of ELL students
  • 8. Most Common Languages in the District Spanish Pohnpeian, Kosrean, Paluan (each) Samoan, Tagolog, German (each)
  • 9. Assessments We Currently Have Based on the test list from the IRC
  • 10. Name Area Ages Summary # Preschool Language Scale 5 Spanish Receptive and Expressive Language 0- 7;11 “Normed on 1150 children in the U.S. and Puerto Rico. Can identify language delays/disorders in Spanish speakers or bilingual speakers. Ordered differently than the PLS-5 (English): First all receptive (Spanish, English), then all expressive (Spanish, English).” (Source: Bilinguistics) 1 Expressive One Word Picture Vocabulary, Spanish/Bilingual Ed. Expressive Language 2;0- 70;0 “Assesses expressive single word vocabulary. For bilingual students can hint towards need for dynamic intervention where concepts are taught prior to use of concepts in intervention session.” (Source: Bilinguistics) 2 Receptive One Word Picture Vocabulary Test Spanish/Bilingual Ed. Receptive Language 2;0- 70;0 “Assess receptive single word vocabulary. For bilingual students can hint towards need for dynamic intervention where concepts are taught prior to use of concepts in intervention session.” (Source: Bilinguistics) 2 Clinical Evaluation of Language Fundamentals 4- Spanish Ed. Receptive and Expressive Language 5-21 Subtest scores are divided into areas of need. Vocabulary score is a good indicator of language ability for bilingual students, especially if taken as part of a total vocabulary. (Source: Bilinguistics) 2 Goldman Fristoe Test of Articulation-3 Spanish Articulation “The GFTA-3 Spanish is not a translation of the English edition. While much of the art is shared across the English and Spanish editions, scoring is based on phoneme production of words in Spanish.” (Source: Pearson) 1
  • 11. Norm-Referenced Assessments to Consider for Purchase Based on “Common Communication Measures” from Bilinguistics
  • 12. Name and Price Area Ages Summary The Bilingual Spanish English Assessment (BESA) $550 All major communicati on areas 4;0- 6;11 “The BESA is a language evaluation to use with young Spanish/English bilingual children. It has two questionnaires and divides the testing area into three subtests (Semantics, Morphosyntax, and Phonology). There is an additional Pragmatic Language Area that is not scored. Components can be used independently or as an assessment battery.” (Source: Bilinguistics) Bilingual Articulation and Phonology Assessment (BAPA) $45 unlimited administrations. Articulation and phonology 3;0- 10;11 “The BAPA is an iPad Test for both monolingual and bilingual children. Both languages can be tested, responses are marked and tabulated as you progress. The results, scores, and tables are created immediately upon completion. Sound prompts, recording productions, and repetitions are all possible.” (Source: Bilinguistics) Norm-Referenced Assessments to Consider for Purchase
  • 13. What else is available: Questionnaires • “Intelligibility in Context Scale for Parents and Teachers.” Available in multiple languages. Link is on Schoology. • We have the ASQ and the DIAL-4 parent questionnaires available in Spanish. • The Speech Participation and Activity Assessment of Children (SPAA- C). Link is on Schoology.
  • 14. What else is available: Nonstandard • SALT software and Narrative Scoring scheme: https://www.saltsoftware.com/media/wysiwyg/codeaids/NSS_Scoring_Guide.pdf • Language sampling considered the “gold standard”. • English/Spanish Comprehension questions for the story “Frog Where are You?” file:///C:/Users/bridgetmooney/Downloads/Frog-Where-Are-You-Comprehension-Questions-Eng-and- Spn.pdf • Rojas and Iglesias (2009) recommended three specific measures for use with Spanish–English bilingual speakers: mean length of utterance in words (MLUW), number of different words (NDW), and words per minute (WPM). MLUW indexes syntactic skill, NDW measures lexical diversity, and WPM indicates overall verbal fluency
  • 15. What else is available: Nonstandard • Spanish Phonology Test. 100 word phonology test in Spanish and English. Supplemental cluster lists and a screener are also available in both languages and can be found at: https://phonodevelopment.sites.olt.ubc.ca/practice-units/spanish/ • Bilingual Communication Assessment Resource Book. • Other ideas?
  • 16. Questions for you: What do we need? • What languages? Tagalog. Puerto Rican Spanish Pohnpeain • What age groups? About 3rd grade. • What areas of communication? BVAP • How often have you utilized parent or teacher questionnaires as part of bilingual assessment? • How often is your ELL teacher in the building? Are you able to utilize them as a resource when testing?
  • 17. What other support would help? • CEUs? • Aide/Interpreter training? • More conversations/training with or from the ELL department?
  • 18. References • Bedore, L.M., Peña, E.D., Gilliam, R.B. & Ho, T.S. (2010). Language sample measures and language ability in Spanish-English bilingual kindergarteners. • Brice, A.E., & Brice, R.G. (2007). A tale of two languages. ASHA Leader. 12 (13), 14-39. • Dollaghan, C. A. & Horner, E. A. (2011). Bilingual language assessment: A meta-analysis of diagnostic accuracy. J Speech Lang Hear Res, 54(4), 1077-1088. doi: 10.1044/1092- 4388(2010/10-0093). • Ebert, K. D., & Pham, G. (2017). Synthesizing Information From Language Samples and Standardized Tests in School-Age Bilingual Assessment. Language, speech, and hearing services in schools, 48(1), 42–55. https://doi.org/10.1044/2016_LSHSS-16-0007 • Goldstein, B., Pena, E.D., Kiran, S., Mahendra, Gabrielsa, S.C. (2017). 2 Languages 2 Worlds. Retrieved from: https://2languages2worlds.wordpress.com/ • Grob, A., Keller, K., & Troesch, L.M. (2015). A large receptive–expressive gap in bilingual children. Frontiers in Psychology. 6: 1284 Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548084/. • Guo L-Y, Eisenberg S. Sample Length Affects the Reliability of Language Sample Measures in 3-Year-Olds: Evidence From Parent-Elicited Conversational Samples. Language, Speech, and Hearing Services in Schools. 2015;46(2):141-153. doi:10.1044/2015_LSHSS-14- 0052.
  • 19. References cont. • Hammer, C. S., Komaroff, E., Rodriguez, B. L., Lopez, L. M., Scarpino, S. E., & Goldstein, B. (2012). Predicting Spanish–English bilingual children’s language abilities. J Speech Lang Hear Res, 55(5), 1251-1264. doi: 10.1044/1092-4388(2012/11-0016). • Heilmann, J., Nockerts, A., & Miller, J. F. (2010). Language Sampling: Does the Length of the Transcript Matter?. Lang Speech Hear Serv Sch, 41(4), 393-404. doi: 10.1044/0161-1461(2009/09-0023). • Kritikos, E.P. (2003). Speech-Language Pathologists' beliefs about language assessment of bilingual/bicultural individuals. American Journal of Speech-Language Pathology. 12, 73-91. doi:10.1044/1058-0360(2003/054). • Levey, S. & Sola, J. (2013). Speech-language pathology students’ awareness of language differences versus language disorders. Contemporary Issues in Communication Sciences and Disorders, 40, 8-14. Retrieved from: http://www.asha.org/uploadedFiles/ASHA/Publications/cicsd/2013S-Speech-Language-Pathology-Students- Awareness.pdf. • National Center for Education Statistics (2016). English language learners in public schools. NCES. Retrieved from: http://nces.ed.gov/programs/coe/indicator_cgf.asp. • Patterson, J. L. (1998). Expressive vocabulary development and word combinations of Spanish-English bilingual toddlers. Am J Speech Lang Pathol, 7(4), 46-56. doi: 10.1044/1058- 0360.0704.46. • Peña, E. D., Gillam, R. B., Bedore, L. M., & Bohman, T. M. (2011). Risk for poor performance on a language screening measure for bilingual preschoolers and kindergarteners. Am J Speech Lang Pathol, 20(4), 302-314. doi: 10.1044/1058-0360(2011/10-0020). • Rose, K., Armon-Lotem, S., & Altman, C. (2022). Profiling Bilingual Children: Using Monolingual Assessment to Inform Diagnosis. Language, speech, and hearing services in schools, 53(2), 494–510. https://doi.org/10.1044/2021_LSHSS-21-00099
  • 20. How ELL Serves our Students •Push-in and pull-out services are offered to support academics and English language development •ELL aides act as verbal interpreters and written translators for students and families at IEPs, conferences, and throughout the school day. •ELL teachers educate staff on native language and assist with navigating cultural differences.
  • 21. • **Please note, the ______ (test name) is not normed on bilingual speakers and does not take into account differences in non-American dialects, or customs/cultural expectations that may influence a child’s responses. In these scenarios, standardized assessments may be administered dynamically. Thus standard scores should be taken with caution and understood in that context. They do not represent a complete picture of ______ (student’s name) abilities. A further content analysis of developmental skills is included below**

Editor's Notes

  1. Without background knowledge of a language, transfer can easily be mistaken for a mistake.
  2. Per the American Speech Language Hearing Association’s (ASHA) Code of Ethics (2016), ethical delivery of treatment by speech language pathologists and audiologists is to include cultural competency for non-English speakers and English Language Learners. Whenever possible, patients are to be assessed in English and their native language in order to have a comprehensive picture of their language capabilities.
  3. https://www.asha.org/practice/multicultural/phono/ https://accent.gmu.edu/browse_native.php
  4. most recent meta analysis I could find on diagnosis accuracy: Bilingual Language Assessment: A Meta-Analysis of Diagnostic Accuracy (Dollaghan & Horner, 2011) over or under diagnosis of language delays or disorders in bilingual children. Sensitivity: the ability of a test to correctly identify patients with a disease. Specificity: the ability of a test to correctly identify people without the disease. True positive: the person has the disease and the test is positive. True negative: the person does not have the disease and the test is negative. Profiling Bilingual Children: Using Monolingual Assessment to Inform Diagnosis Karen Rose ,  Sharon Armon-Lotem  and  Carmit Altman
  5. Numbers courtesy of Susan Pender and are from the 2021-2022 school year. Why does elementary have the highest population of ELL students? What happens?
  6. Pohnpeian and Kosrean and are spoken in the Federated States of Micronesia, an island nation in between Indonesia and Australia Source: Susan Pender
  7. Sources: Doris Henderson, IRC “Common Communication Measures” from www.bilinguistics.com
  8. Artic: BAPA   Language: TELD-3 because of the large age-range BESA because of the flexibility of using different subtests or questionnaires, or giving the whole battery. Also flexible for bilingual speakers as opposed to mono-lingual speakers
  9. Question for Nate: How do we access the ASQ? “SPAA-C originally was developed to provide speech-language pathologists with information about children with speech sound disorders but may also be relevant for considering children's communication more broadly (e.g., with children who are multilingual, children who stutter, children who have language disorders, children with hearing loss). The questions can be adapted to suit the context.” : “Ages 3 through adult.This comprehensive NEW resource includes information about assessing individuals with communication disorders and practical REPRODUCIBLE assessment forms that you can use with children and adults. In addition to structured assessment tasks, observational assessment tools are included that can be used with speakers of any language. Most of the assessments are designed for individuals five years of age and up. Some of the assessment procedures and materials can be used with children as young as age 3. Reproducible measures are included for assessing the articulation, language, voice, and fluency skills of Spanish speakers. Many of these assessments can be adapted easily for use in other languages. Users of other inventories such as Spanish Language Assessment Procedures, will find this book extremely valuable when additional information is obtained in specific areas.”
  10. Bilingual Assessment is often dynamic. Language sampling considered the “gold standard”. SALT software has proven valid for this analysis Heilmann et al., 2016), Language samples capture contextualized skills that may align with academic language demands (Bedore, Peña, Gillam, & Ho, 2010). Collection of language samples is quick and can be adapted to the child and the setting; for bilingual children, language samples can be collected in a home language via collaboration with an interpreter or trained bilingual paraprofessional
  11. “Sheltered” or translated kindergarten is offered at other schools in our district for children who benefit from extensive translation due to limited English exposure before starting school.  Additionally