Swallowing and Feeding Issues with Internationally Adopted Children

Vegetables in Whole Foods Market

Photo by Masahiro Ihara

My children were “picky eaters.” One would only eat peanut butter and jelly, frozen pizza, chicken nuggets or macaroni and cheese. The other one would only eat frozen pizza and hot dogs. Neither of them would eat any vegetables. If it was green, it was considered inedible! Needless to say, cooking for them was a challenge. Somehow they survived and are both healthy adults who eat more variety than I ever thought they would.

Many of our food preferences are based on our food experiences. Children residing in orphanages have feeding experiences that are affected by the number of staff available to feed large groups of infants and toddlers. Parents have reported observing children left in their cribs with bottles propped up to allow self-feeding, given plates of food too hot to eat without utensils to feed themselves, and children fed pureed instead of solid foods. These experiences may not only affect physical growth and nutrition but also adversely affect eating and swallowing development. Some researchers have reported a wide range of eating and swallowing problems from clinical samples including (a) chewing problems, (b) preoccupation with food availability, (c) gorging and (d) sometimes becoming omnivorous (Johnson & Dole, 1999). Others found that 15% (21 of 144 children adopted from Romania) continued to have chewing and swallowing problems at 6 years old, 2 to 5 years following adoption (Beckett, et al., 2002). Beckett and colleagues also found that if solid food was not introduced before the age of 1 year, more of these children had continued eating and swallowing problems. Many of the children seen at the Saint Louis University International Adoption Clinic present with eating and swallowing difficulty or unusual oral motor problems such as facial tics or intermittent velopharyngeal closure during speech and swallow.

Children adopted from abroad are at risk of having eating and swallowing problems. Practitioners are advised to explore the presence of oral motor sensitivity, eating and swallowing problems with the client or client’s family. If problems were observed or continue to occur, a thorough assessment of oral motor structures and function and possibly an assessment of eating and swallowing behaviors may be needed. If children demonstrate eating disorders related to mental health issues such as bulimia or anorexia, it is important to refer them to clinical psychologists or counseling and family therapists.


Beckett, C. M., Bredenkamp, D., Castle, J., Groothues, C., O’Connor T. G., Rutter, M., & the
English and Romanian Adoptees (ERA) Study Team. (2002). Behavior patterns associated with institutional deprivation: A study of children adopted from Romania. Journal of Developmental and Behavioral Pediatrics, 23(5), 297-303. http://journals.lww.com/jrnldbp/pages/default.aspx

Johnson, D. E., & Dole, K. (1999). International adoptions: Implications for early
intervention. Infants and Young Children, 11, 34-45. Retrieved from:

Deborah Hwa-Froelich, Ph.D., CCC-SLP, is a Saint Louis University professor and Director of the International Adoption Clinic with interests in social effects on communication such as culture, poverty, parent-child interaction, maternal/child health, and disrupted development.


Apps for Bilingual SLPs and English-speaking speech therapists working with Spanish-speaking children.

I am a bilingual speech pathologist, and for those of you who work with Spanish-speaking children you know how frustrating it can be trying to get ready for therapy. Most of the time we are limited to two options: live translation of English materials or spending hours creating our own Spanish materials. The limited resources in Spanish pushes us to creating our own materials on a daily basis. This can be very difficult for us with an already very limited time on our hands to serve so many children. Thanks to the iPad and the iPhone, developers all around the world are creating apps. This allows us to take advantage of the apps produced in Spanish that can be purchased anywhere. The number of apps in Spanish is still very limited in comparison to apps in English. However, the ease of development of the apps makes it a lot easier for us therapists to access products in other languages. Here are my top 5 apps in Spanish that can be used in therapy:

1. Spanish Articulation Probes

Bilingual slp app logoThis app allows therapists and parents to work on specific sounds. It works like flashcards. It contains over 500 flashcards in it separated by specific phonemes, mode of articulation, and phonological processes. This is a very useful app not only for bilingual therapists, but also for English-speaking clinicians who should work on speech errors in both languages when treating children with articulation delays.

2. Learn Spanish and Play

Learn and play app logoThis is an app for working on basic vocabulary and even categorization. Choose from one of (the) 8 scenes: “granja, Zoologico, Insectos, Mar, Frutas, Hortalizas, Colores and Familia”. There is a teaching and a testing component to this application. Once you have worked on the vocabulary you can go to play game mode and test for learning of vocabulary.

3. Play2learn

Play2learn app logoThis Spanish app is part of a family of apps in several languages, including Russian, Italian, French and other languages. It is very useful if your caseload comprises of students coming from several countries and you want to work on some basic vocabulary on their first language. Play2learn is also an app for basic vocabulary, but with a few more options than Learn Spanish and Play. It contains concepts such as body parts, clothing items, toys, colors, technology vocabulary and many more. It also has a component for verifying learning with coloring activities.

4. Conjugation Nation

conjugation nation logo
This is an app for more advanced learners working on subject-verb agreement in Spanish. The user is given a verb and a pronoun and must type the correct verb conjugation. This is a basic app but is one of the best tools I have ever seen for working on subject-verb agreement: a very prominent feature of Spanish grammar.

5. Spanish Grammar: Ser/Estar

Spanish grammar app logoThis app, despite being a bit difficult to set up is very useful for teaching the differences between “ser/estar” both translated as “to be”(“to/be”) in English but used differently in Spanish. This app gives users lots of ways in which each can be used.

I hope you enjoyed this post. If you have any suggestions of apps in Spanish please send me an e-mail to geekslp@yahoo.com. I would love to post it on my blog. Also keep in mind that any of these apps can also be very useful for English-speaking clinicians trying to brush up or start up on their Spanish skills.

Barbara Fernandes is a trilingual speech and language pathologist. She is the director of Smarty Ears and the face behind GeekSLP TV, a blog and video podcast focusing on the use of technology in speech therapy. Barbara has also been a practicing speech therapist both in Brazil and in the United States. She is a an active participant of the Texas Speech and Hearing Association as a member of the TSHA Culturally and linguistically diverse issues task force. Barbara has created over 15 applications for speech therapists.

Assessing Language Development in Internationally Adopted Children

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Being the proud grandmother of two bright and charming grandchildren, I can’t help but keep track of their development. My son often asks me to “assess” his children’s development. He, like many parents, hope that their children are like Lake Wobegone residents in that they are all above average. My grandson is like most toddlers, babbling and using CVs and CVCs with meaning but sometimes we adults have to fill in missing consonants and words to arrive at his intended communication. Still my son wants to know, is he developing typically?

Parents who have adopted children from abroad often ask me the same question, is my child developing like other children who have been adopted from abroad? Before children are adopted, they are born in different countries of origin and exposed to different birth languages ranging from African or Asian languages to Russian or other Slavic languages. When children have been exposed to different languages and are adopted by a family who does not speak the child’s birth language, the child stops listening to or expressing his or her birth language within 3 to 6 months (Nicoladis & Grabois, 2002). Regardless of the child’s birth language (Russian, Korean, or Chinese), research studies, clinical reports and case studies have provided evidence that children between the ages of 1 and 5 years old who are adopted from different countries demonstrate similar phonetic and phonological development with little first language interference (Glennen, 2007, 2009; Pollock, 2007). If a child demonstrates poor intelligibility or delayed articulation or phonological development, they should be referred for assessment by a speech-language pathologist familiar with research on internationally adopted children.


Glennen, S. (2007). Predicting language outcomes for internationally adopted children. Journal of Speech, Language and Hearing Research, 50, 529-548. doi:10.1044/1092-4388(2007/036)

Glennen, S. (2009). Speech and language guidelines for children adopted from abroad at older ages. Topics in Language Disorders, 29(1), 50-64. doi:10.1097/TLD.0b013e3181976df4

Nicoladis, E., & Grabois, H. (2002). Learning English and losing Chinese: A case study of a child adopted from China. The International Journal of Bilingualism, 6(4), 441-454. doi:10.1177/13670069020060040401

Pollock, K. E. (2007). Speech acquisition in second first language learners (Children who were adopted internationally). In S. McLeod International guide to speech acquisition (Pp. 107-112). New York: Thompson-Delmar Learning.

More abstracts of Karen Pollock’s research on speech-language development in children adopted internationally

Deborah Hwa-Froelich, Ph.D., CCC-SLP, is a Saint Louis University associate professor and International Adoption Clinic coordinator with interests in social effects on communication such as culture, poverty, parent-child interaction, maternal/child health, and international adoption.

Multilingual Typicality vs. Speech-language Disorder

table with coffee mugs and maps

Photo by minka6

Any assessment involves a comparison. For assessment purposes, we use comparison always one way. We compare X to Y, never Y to X, because we have satisfied ourselves of two conditions: first, that Y is a reliable benchmark, which specifies a particular norm of behaviour, including linguistic behaviour; and second, that the behaviour of X can be fairly assessed through the use of that benchmark.

Reliable benchmarks are norm-referenced and standardised for particular populations. Since different populations use different languages and different varieties of the same language, we seek to provide ourselves with developmental and/or clinical assessment instruments which are normed accordingly. We know that it would be as unfair to test, say, users of Korean with instruments normed for Portuguese as to test users of Canadian French with instruments normed for Belgian French. Although we still lack normed instruments for most languages and language varieties, limitations imposed by assessment in these less than ideal conditions are well understood. In monolingual settings, with monolingual clients, clinical practices take them into account.

Concerning multilingual clients, however, the situation is quite distinct. In what follows, I take the words multilingual and multilingualism to refer to users/uses of more than one language, that is, to include bilingual(ism), trilingual(ism), and so on.

One first observation is that multilinguals stand for a disproportionate number of referrals to both special education and speech-language therapy, compared to monolinguals. We may start by asking ourselves why multilinguals are consistently compared to monolinguals, but not the other way around. The reason is that monolingualism has been assumed as a norm of linguistic usage, which has besides become synonymous with cognitive, social and linguistic health. The reason for this, in turn, is that the first researchers who addressed multilingualism were monolingual, or subscribed to monolingual approaches to language, or both. The tradition of thought that they initiated almost one century ago lingers on, and shapes the many misconceptions surrounding multilingualism. A few examples follow, showing how these misconceptions are interrelated and entail one another:

  • “Multilinguals are special.” In monolingual countries and settings, multilingualism is viewed as the special case of language uses. Clients who are multilingual are labelled as such, whereas clients who are monolingual are not labelled as monolinguals. Given that multilinguals outnumber monolinguals worldwide, it cannot be the case that the majority of the world’s population is “special”. The century-old tradition that takes multilingualism as special started by also taking it as the correlate, and sometimes even the cause, of diverse cognitive, social and linguistic shortcomings. The current emerging trend, that lauds multilingualism as unquestionably positive, simply perpetuates the (mis)perception that multilinguals are “special”.
  • “Multilingualism means equivalent proficiency in all languages.” This assumption is better described by a term that I coined, multi-monolingualism, to label the underlying belief that a multilingual equals several monolinguals. This is not what multilingualism is. If multilinguals could (or should) use all their languages in exactly the same way, they would not need several languages: one all-purpose language would be enough. “One all-purpose language” defines a monolingual, not a multilingual. Multilinguals use their languages in different ways, with different people, in different situations, for different purposes. This is why their languages develop differently and cannot therefore be made equivalent.
  • “Ability in one language reflects language ability.” Clinical findings about one of the languages of a multilingual client are often taken as a reliable reflection of the client’s overall language ability. “Language ability” concerns the whole of an individual’s linguistic repertoire, not ability in a particular language. Taking the one for the other means taking a multilingual for a monolingual. The full linguistic repertoire of a monolingual does consist of a single language, but the full linguistic repertoire of a multilingual does not.
  • “Multilinguals can be fairly assessed through monolingual instruments .” The assessment instruments that are  available to us so far are monolingual, and naturally reflect monolingual norms. In addition, multilinguals tend to be assessed either in mainstream languages, or in languages for which assessment instruments have been standardised, neither of which may accurately portray the clients’ linguistic ability. In the absence of normative guidance about multilingualism, skewed findings about multilingual behaviour are to be expected. False positives, where typical multilingual behaviour is mistaken for disorder, account for the disproportion of referrals mentioned above. But, equally seriously, false negatives mistake disorder for typical multilingual behaviour, and so fail to identify disordered multilingualism.

Ideally, then, we should provide ourselves with standardised instruments devised for multilingual uses of language, based on multilingual norms of usage. These norms are not, as I hope to have made clear above, “multi-monolingual”: there are typical behaviours among multilinguals, just like there are typical behaviours among monolinguals. The difference is that we have failed to pay attention to the former, because we have taken the latter as the benchmark of linguistic behaviour across the board. The issue here, as always, is that without knowing what is typical, we cannot tell what is deviant.

Current developments, which take a fresh look at multilingualism, from a multilingual perspective, already show promising results. One example concerns mixes, the use of features of several languages in the same utterance or exchange. Mixes have been stigmatised as instances of “semilingualism”, whereas they are a multilingual norm of usage. The regularity of mixed patterns in typical multilingual speech has been found to aid in the diagnosis of SLI (specific language impairment), in multilingual children whose mixing patterns deviate from the norm. Another development concerns the use of what is known as dynamic assessment, in clinic. Dynamic assessment methods involve teaching and testing linguistic items and structures that are independent of particular languages, and that therefore probe for language ability, not ability in particular languages.

Growing awareness about the lack of multilingual norms also impacts the clinicians themselves. To the best of my knowledge, professional training of SLPs does not include information about languages other than the language of intervention, or about multilingualism itself. This is so even for multilingual SLPs, or for those who plan to practise in multilingual settings. Many SLPs thus encounter multilingualism for the first time in clinic, where the “special” status accorded to multilinguals may well shape expectations about multilingual clients. There is of course no requirement that SLPs become multilingual. Being multilingual does not mean understanding what multilingualism is: misconceptions about multilingualism are shared by monolinguals and multilinguals alike. The requirement is that SLPs, and the rest of us, become familiar with what multilingualism is, so we satisfy ourselves that, while we wait for the standardisation of multilingual norms, we are giving multilinguals a fair assessment chance.

Multilingualism is not about what several languages can do to people, it is about what people can do with several languages. The same can be said about monolingualism and a single language: the number of languages that people happen to need to use in order to function appropriately in their everyday environments has little to do with their language ability, just like the number of musical instruments that one plays has little to do with one’s musical ability.

One final note: I have discussed multilingual assessment in my blog, which is geared to a general audience, in a post titled The fight for a fair deal. For more specialised research and findings on multilingual typicality, my book Multilingual Norms may be of relevance.

Madalena Cruz-Ferreira, PhD in Linguistics and Phonetics (University of Manchester, UK), researches multilingualism and child language. One section of her book Multilingual Norms addresses multilingual clinical assessment. Her blog Being Multilingual deals with the use of several languages at home, in school and in clinic.