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Profiling performance in L1 and L2 observed in Greek-English bilingual

aphasia using the Bilingual Aphasia Test: A case study from Cyprus

Article  in  Clinical Linguistics & Phonetics · March 2011

DOI: 10.3109/02699206.2011.563899 · Source: PubMed

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Profiling performance in L1 and L2 observed in Greek–English bilingual aphasia using the Bilingual Aphasia Test:a case study from Cyprus

MARIA KAMBANAROS & KLEANTHES K. GROHMANN

Department of English Studies, University of Cyprus, Nicosia, Cyprus

(Received 30 November 2010; Accepted 14 February 2011)

AbstractThe Greek and the English versions of the Bilingual Aphasia Test (BAT) were used to assess thelinguistic abilities of a premorbidly highly proficient late bilingual female after a haemorrhagiccerebrovascular accident involving the left temporo-parietal lobe. The BAT was administered in thetwo languages on separate occasions by the first author, a bilingual English–Greek speech pathologist.The results revealed a non-parallel recovery in the two languages. This information will be used not onlyto guide clinical intervention for the patient but also to provide the first report on the manifestations ofaphasia in Greek. Moreover, the use of the (Standard Modern) Greek version of the BAT to investigateGreek Cypriot aphasics has implications for the use of the BAT on underspecified languages or dialects.Such studiesmay help with the development of assessmentmeasures and therapy strategies that focus onspecific characteristics of one or multiple languages.

Keywords: Cypriot Greek, diglossia/bidialectism, language assessment, recovery patterns, underspecified/understudied languages, multilingualism, aphasia

Introduction

More than half the world’s population is bi-, even multilingual, and in our daily lives we allincreasingly come into contact with languages and cultures other than our own. Europe hasalready realized that there is a need to generate a greater interest in languages among itscitizens (CEF, 2000), partly due to the fact that ‘bi[/multi]lingualism brings with it manybenefits: it makes the learning of additional languages easier, enhances the thinking processand fosters contacts with other people and their cultures’, as the Council of Europe listedamong their ‘language facts’ on the occasion of the recent EuropeanDay of Languages (http://edl.ecml.at/LanguageFun/LanguageFacts/tabid/1859/language/en-GB/Default.aspx).

Moreover, most countries in Europe have a number of regional or minority languages –some, but not all, of these have obtained official status.1 On the one hand, then, Europe hasbecome largely multilingual and people’s motivations behind the learning of a secondlanguage vary from economic migration to achieving better job prospects and community

Correspondence:MariaKambanaros,UniversityofCyprus,75Kallipoleos,P.O.Box20537,1678,Nicosia,Cyprus, .E-mail: kambanaros@gmail.com

ISSN 0269-9206 print/ISSN 1464-5076 online © 2011 Informa UK Ltd.DOI: 10.3109/02699206.2011.563899

Clinical Linguistics & Phonetics, June–July 2011; 25(6–7): 513–529

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integration; it is thus becoming increasingly common for people to speak more than onelanguage. On the other hand, our theoretical and clinical understanding of language break-down due to brain injury in two (or more) languages remains poorly understood (Lorenzenand Murray, 2008; Kambanaros, 2009).

The key issue addressed in the research reported here is how injury to the brain compro-mises the language faculty and, especially in the case of bi- or even multilingualism, how thespecific structure of each language is affected. Damage to one ormore of the language areas ofthe brain, most commonly after stroke, results in aphasia. Aphasia, when acquired, affects theexpression and understanding of language as well as reading and writing. Aphasia may alsoco-occur with motor speech disorders, such as dysarthria or apraxia of speech, which alsoresult from brain damage. Although different languages have many things in common whenspecific portions of the brain are injured, there are also many differences. Neurolinguisticresearch focuses on identifying the common (or even universal) symptoms of aphasia and thelanguage-specific symptoms of the disorder.

The roadmap for our article is as follows. After introducing some relevant background onbilingual aphasia, we will present the case study of a Greek Cypriot multilingual aphasicparticipant and discuss the results from the Bilingual Aphasia Test (BAT: Paradis andLibben, 1987) carried out in (Standard Modern) Greek and in English. In this context, wewill briefly address the ‘dialectal’ issue of Cypriot Greek, an understudied language, and pointto some shortcomings of the adapted Greek version of the BAT, independent of that issue.We will conclude by putting particular matters arising from the case study into a largercontext.

Bilingual aphasia with a twist

Bilingual aphasia provides the ideal opportunity for a multidisciplinary approach to the under-standing of aphasia by taking into consideration the unique skills of bilingual speakers com-pared with monolinguals; indeed this article grew out of an ongoing collaboration between aspeech pathologist and a linguist. Aphasia is an impairment of implicit linguistic competence,where metalinguistic knowledge and pragmatics are neurofunctionally independent of suchimplicit linguistic competence. Conceptually, Paradis (2004) suggested that aphasia not beconsidered as damage to or destruction of a language system, but as an act of inhibition of (partsof) the language system. Moreover, implicit linguistic knowledge (what one knows about theirlanguage) is vulnerable to aphasia that is acquired incidentally and not only stored implicitly butalso used automatically and hence sustained by procedural memory.

From the breadth of studies carried out in the field of neurolinguistics pioneered byMichelParadis over the last four decades (starting with Paradis, 1977), we know that, despite thelanguages of bilingual speakers sharing a more or less common neuronal and conceptualsystem, not all languages are impaired to the same extent in the case of bilingual aphasia.Perhaps the first language (L1) is affected worse than the second language (L2), or the otherway round. Moreover, languages may show different patterns of recovery after aphasia onset.But why this is the case remains unresolved and an area of continuing research and debateacross fields, including linguistics or brain imaging, and disciplines as different as psycho-linguistics, neurolinguistics and neuropsychology (Green, 2008).

Several factors have been considered to affect the recovery process and contribute todifferential L1/L2 recovery. Initially, it was suggested that the native or the last languageused before the stroke would be the first to recover (Paradis, 1983). This has yet to be provenempirically. Similarly, language dominance pre- and/or post onset was suggested as a

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contributing factor. Nor does it seem that recovery reflects how or the order in which thelanguages were acquired or used premorbidly. Moreover, no strong connection has beenestablished between the structural characteristics (similar vs. dissimilar) of the two languagesand recovery pattern or the localization of languages in the brain. Also, aphasia type withinand across the two languages may play a role in the recovery pattern.2

A further prominent explanation links recovery patterns to the differential effects of braindamage underpinning the declarative/procedural memory systems as a factor of age ofacquisition. For example, when L2 is acquired after late childhood or puberty, the declarativesystem will take over the role of the procedural system in the production of syntactic formsthat rely on this system in L1. Thus damage to the procedural system will impair L1 morethan L2, but this might not be the case if the individual is highly proficient in L2 (see Ullman,2001, 2004). For Paradis (2004), differential or selective recovery of L2 over L1 is related toconscious metalinguistic knowledge for L2 not evident for LI.

Finally, it has been argued that the type of recovery pattern may not be related to differentialrepresentation but linked instead to a control mechanism in the brain. This hypotheticalmechanism distributes resources among the various languages spoken (Green, 2005; Abutalebiand Green, 2007). In the case of parallel recovery, the control system distributes resourcesequally to the two languages. In contrast, in the case of differential recovery, one languagereceives more resources than the other and thus recovers sooner. In fact, non-parallel recoverypatterns may be found in the mechanisms of (dis)inhibition affecting the neural substratesubserving language competence (Paradis, 2004: 54). The reader is referred to Paradis (2004:63–68) for a description of the recovery patterns of published cases of bilingual aphasia.

Approaching the second decade of the new millennium, the aphasia literature still lacks in-depth studies on bilingual, and certainly multilingual, language assessment across differenttypes of bilingual users such as early versus late, different language pairs/combinations andneurological conditions. To ensure better practice, the assessment of aphasia in both lan-guages is of paramount importance. Clinicians have a professional obligation and ethicalresponsibility (Fabbro, 2001; Kambanaros, 2009) to their clients to increase diagnosticaccuracy and provide a comprehensive picture of residual communication ability for use inplanning treatment (Baker, 2002; Kambanaros, 2003). As Paradis (2001: 5) said, ‘it isimportant for one to be aware of the particular manifestations of aphasic symptoms in agiven language or family of languages, namely, to avoid misdiagnosis.’

For the purpose of this special issue on the BAT and its uses, we report the nature of thelanguage deficits in a multilingual (Cypriot) Greek–English speaker with aphasia. The twoversions of the BAT, in (Standard Modern) Greek and in English, are considered linguisti-cally equivalent and culturally appropriate tests rather than translations of each other(Paradis, 2004, this issue). By comparing performance across the two language pairs, theimpact of aphasia on each language for comprehension, spoken and written language pro-duction will allow us to determine the level of linguistic breakdown for each language. Ourparticipant’s results from the BATwill also allow us to focus on the range of recovery patternsin terms of the impact of the impairment on the two languages (Paradis, 1977). Bilingualaphasia differentiates itself frommonolingual aphasia in this respect, and this has implicationsfor intervention (e.g. unilingual vs. bilingual therapy).3

Given that no formal standardized test is available in Greek to assess aphasia,4 let aloneCypriot Greek (for which very little work has been done in general and none on aphasia), theBAT remains the only published assessment available for monolingual Greek speakers andbilingual speakers of Greek (as either L1 or L2) several years after its conceptualization andfirst use. However, the BAT is not a norm-referenced standardized test; it does not provide

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(bilingual) norms to compare brain injured with non-brain injured individuals acrosslanguages.

Moreover, unlike the Boston Diagnostic Aphasia Examination, the BAT does not classifypatients based on their performance into aphasia subtypes or aphasic syndromes. This shouldnot be considered a limitation of the test, but a significant advantage, because it allowsclinicians to adopt the theoretical and clinical framework more suited to their own or workplace philosophy of practice (e.g. impairment-based vs. socially based assessment and inter-vention for aphasia), as is the case when dealing with monolingual clients with aphasia.

Furthermore, if the clinician does not speak the client’s other language(s), then, accordingto Paradis and Libben (1987), family informants and/or interpreters can be trained toadminister the BAT assessment materials. There is a large literature on professional guide-lines, including the pitfalls to avoid when collaborating with interpreters (see ASHA, 1989;Langdon, 2002; Kambanaros and van Steenbrugge, 2004). However, for the analysis andinterpretation of the assessment results, a professional with theoretical and clinical knowledgein the area of bilingual aphasia must be employed, such as a speech pathologist, an aphasiol-ogist or a neurolinguist.

Case Report

Our participant, PK, is a 40-year-old right-handed female who sustained a severe intracer-ebral haemorrhage of the left temporo-parietal lobe as revealed by CT scan, in December2009. A craniotomy was performed and the large haematoma was removed as well as parts of

Figure 1. A CT scan of PK’s brain revealing the large haematoma in the left temporo-parietal lobe.Source: Nicosia General Hospital, 9 December 2009, 5.53 pm (I.D. and D.O.B. provided).

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the meninges that were later replaced with synthetic material. The CT scan information isavailable in Figure 1.

After surgery, according to the neurological report, the participant presented with a mildspeech disorder and 9 days later was dismissed from the hospital. She received speech andlanguage therapy for 3 months post stroke for her communication difficulties, mainly com-prehension and word-finding deficits, in Greek only. She also presented with a mild righthemiparesis (arm and leg) and hemianopia that are now completely resolved. Her post-surgery recovery up until now has been unremarkable. She is, however, on antiepilepticmedication (levetiracetam: Keppra) as a precaution. She had no premorbid communication,reading or writing disorder and she did not suffer from any psychiatric illness includingdepression or substance abuse. She has normal hearing and vision. She is married with twoyoung children.

The BAT is divided into three parts. Part A is a case history or bilingual questionnaire, PartB contains the language-specific test and Part C deals with the specific language pair test. Wereport our findings for PK in the following under each subpart (A–C).

Case history: PK

The case history following the BAT format was conducted in Greek upon our participant’schoice, and all information and testing was gathered in her home. The first part of the casehistory (another Part A, which makes accurate reference a little difficult) is common to alllanguages and focuses on the individual’s bilingual language history. The following informationrelates to PK’s exposure to Greek and English from her childhood up until the present time.

PK was born in Cyprus to Greek Cypriot parents. Cypriot Greek was the language spokenat home by her parents and Greek was the official language of her education.5 She first cameinto formal contact with English in her early adolescent years, in high school, where shereceived weekly instruction on the English language and learned to read and write in English.PK went on to complete a bachelor degree in teaching from the Pedagogical Institute ofCyprus, and a diploma in teaching English as a second language (ESL). She had 20 years ofteaching experience, mainly in teaching ESL to primary school children in grades five and six(11–12 years of age) before her stroke. PK is married to a Greek Cypriot who spent severalyears in the United Kingdom studying and working but now permanently resides in Cypruswhere he works as an air traffic controller at the international airport.

Based on the above information, we can conclude that PK is a successive late bilingual whoacquired English in early adolescence, after formal (classroom) instruction. Given the man-ner of acquisition, L2 was consciously learned, with a heavier reliance on the declarativememory system and metalinguistic knowledge. Also, Greek, that is, the standard language,was learnt in school as part of the regular curriculum, similarly enhancing metalinguisticknowledge compared with Cypriot Greek (acquired implicitly; see Conclusion for a slightlyextended discussion).

The second part of the case history (i.e. Part B of Part A of the BAT) focuses on theindividual’s language-specific background for each language acquired. The following infor-mation relates to PK’s use and proficiency in Greek and English. PK has never lived outsideCyprus, but in the past she had travelled extensively abroad with her husband and on suchtrips she mostly communicated in English. The couple often spoke English at home beforeher illness. Our participant was asked to rate (1) her frequency of use of the Greek and Englishlanguages in speaking, reading and writing and (2) her proficiency in English and Greekacross the above-mentioned domains. This information is presented in Table I.

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Based on PK’s self-report and evaluation of her linguistic abilities, we can conclude that shewas premorbidly a highly proficient user of Greek and English and both languages were usedon a daily basis for communication, reading and writing. Both languages were used indifferent domains of life and with different people. For the purpose of presenting assessmentresults from the BAT, we will from now on refer to Greek as (L1) and English as (L2), but seeour brief qualification regarding Cyprus and Cypriot elsewhere, especially in the Conclusion.

Language-specific test: Greek and English

The language-specific test assesses the structural characteristics of each language acrosscomparable linguistic levels (i.e. phonology, morphology, syntax, lexicon and semantics) infour modalities: comprehension, production, reading and writing. This is done by 32 tasks intotal, with 472 items in each language that systematically tap into the language-specificstructures and the language skills of the aphasic individual. The objective is to reliably andvalidly determine with some degree of specificity and sensitivity the extent to which, and inwhich areas, one language may be better preserved than the other, or not. Moreover, byidentifying linguistic areas of difficulty, therapy can be targeted at the appropriate level ofbreakdown to meet the communication needs of the individual.

PK was first tested on the Greek subtest and 10 days later on the English subtest. Eachsubtest required two 1-hour sessions. She was tested in the late phase of her recovery (in thesense of Fabbro, 2001): 7 months post onset on the Greek version and 8 months post onseton the English version. We present our participant’s percentages of correct responses ontasks in L1 and L2 across the linguistic levels (see Figure 2) and for language skills (seeFigure 3).

PK’s individual raw scores in L1 and L2 for all the BAT tasks are presented in Table II.Next, we will describe our participant’s relative strengths and weaknesses across the four

modalities in L1 and L2.Comprehension. In this domain, PK showed no difficulties pointing to named common

objects and following both simple (e.g. ‘Raise your hand.’) and semi-complex (e.g. ‘Put thefork in the glass.’) commands in either language. However, she did have difficulties followingcomplex commands (e.g. ‘Here are three coins. Push the larger coin towards me, turn overthe middle-sized one, and cover the small one with your hand.’) in both L1 and L2, with agreater difficulty in L2 (see Table II). The greater impairment of L2 in this task as well as thepersistence of PK’s difficulties in the comprehension of complex commands in Greek maypoint to a working memory deficit that could underlie her comprehension difficulties forthree-stage commands. Working memory, however, was not formally assessed beyond the

Table I. PK’s rating of use of Greek and English.

Questions (BAT) Greek English

Q9. In your daily life before your illness did you speak English/Greek: 1) Every day; 2) Every week;3) Every month; 4) Every year; 5) Less than once a year

1) 1)

Q12. Before your illness, was your English/Greek reading: 1) Not good; 2) Good; 3) Very good 3) 3)Q13. In your daily life before your illness did you read English/Greek: 1) Every day; 2) Every week;

3) Every month; 4) Every year; 5) Less than once a year1) 1)

Q16. Before your illness, was your English/Greek writing: 1) Not good; 2) Good; 3) Very good 3) 3)Q17. In your daily life before your illness did you write English/Greek: 1) Every day; 2) Every week;

3) Every month; 4) Every year; 5) Less than once a year1) 1)

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BAT items. Her understanding of different sentence types (e.g. pronominal, subject andobject topicalized, negation and reversible constructions) was within normal limits in L1 andL2 apart from her understanding of affirmative standard sentences in L2, where she scoredjust below the normal range.

However, her worst performance for comprehension was on the following four subtestson the English version of the BAT, in order of difficulty: (1) grammaticality judgement, (2)auditory discrimination, (3) semantic acceptability and (4) lexical decision. PK demon-strated moderate difficulties in the grammaticality judgement subtest in L2 (60% correct)compared with L1 (100%). She identified ungrammatical sentences (e.g. ‘The cat is bitingby the dog.’ or ‘The boy not wake up his mother.’) as grammatically correct. Given the smallnumber of items tested, no clear pattern emerged based on the errors. However, it appearedthat PK may have difficulties with the comprehension of tense and passive formation inEnglish (a typical deficit well known from the literature; cf. Grodzinsky, 1990). For theverbal auditory discrimination subtest, she showed amarked difference in correct responsesbetween L2 (66.6%) and L1 (100%). Error analysis in L2 revealed two error types: (1)difficulties differentiating the target word from the phonological foil, that is, distinguishingminimal pairs (e.g. target pear ! bear, target crane ! train) and (2) vocabulary gap where

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Figure 3. PK’s performance in L1 and L2 on different linguistic skills.

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Figure 2. PK’s performance in L1 and L2 on different linguistic levels.

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Table II. PK’s BAT performances in Greek and English.

Subtest Greek English Number of itemsNumber of errorsin normal range

Spontaneous speech 5 5 5 a

Pointing 10 10 10 0Simple commands 5 5 5 0Semi-complex commands 4 4 5 1Complex commands 3 1 5 2b

Verbal auditory discrimination 18 12 18 3Syntactic comprehension (S) 13 12 13 0Syntactic comprehension (P) 6 6 6 1Syntactic comprehension (A) 7 7 8 1Syntactic comprehension (NS1) 8 8 8 1Syntactic comprehension (NS2) 11 11 12 2Syntactic comprehension (Sn) 12 11 12 2Syntactic comprehension (NSln) 12 12 12 3Syntactic comprehension (RP) 16 15 16 1Semantic categories 5 3 5 1Synonyms 5 4 5 1Antonyms 5 5 5 1Antonyms 11 5 4 5 1Grammaticality judgement 9 6 10 1Semantic acceptability 10 7 10 1Repetition 30 30 30 0Judgement 30 22 30 1Sentence repetition 7 6 7 1Series 2 2 3 0Verbal fluency 6 5 6 c

Naming 20 17 20 0Sentence construction 25 23 25 c

Semantic opposites 10 7 10 1Derivational morphology 10 7 10 2Morphological opposites 8 3 10 2Description 3 3 3 a

Mental arithmetic (simple) 5 5 5 0Mental arithmetic (complex) 5 6 10 2Listening comprehension 5 5 5 1Reading (words) 10 9 10 0Reading (sentences) 10 8 10 1Reading (text) 5 5 6 1Copying 5 5 5 0Dictation (words) 3 2 5 0Dictation (sentences) 3 3 5 1Reading comprehension (words) 10 9 10 1Reading comprehension (sentences) 10 10 10 1

Notes: Italicized numbers indicate responses that fall below the normal range. S, simple standard sentences; P,pronominal reference with animate subjects and objects; A, pronominal reference to inanimate gendered nouns orself-reference versus reference to a third person, NS1, passive or similar construction with subject/object word orderchange; NS2, non-standard 2 sentences, Sn, cleft sentences or similar constructions with topicalized subject andtopicalized object, simple standard sentences in the negative; NS1n, passive negative or equivalent construction in thenegative; RP, the possessive.aThe patient’s performance is evaluated in the post-test analysis.bTwo complete items or the equivalent of 8/20.cNorms on these items are given at the end of each version of the BAT.

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words such as jar, cramp or chip were no longer available to her (don’t know-responses). It ispossible that the differences in grammatical judgement performances between L1 and L2are linked to perceptual differences between the two languages given the greater number ofvowels in the English language sound system (about 11) relative to the Greek languagesound system (5). This may be a source of ambiguity for the Greek speaker who learnsEnglish because the shorter distances in the English vowel space might result in lowerauditory discrimination and identification. Also, the location of her lesion is consistentwith an auditory discrimination difficulty.

Similarly, her poorer performance in L2 on the semantic acceptability task (70% correct)was related to her comprehension difficulties for the words gravy, season and (the verb) dribble.This affected her performance on judging if the sentence she heard made sense in English(e.g. ‘The flowers grow in the gravy.’) where she replied with don’t know-responses. Finally,for the lexical decision task in L2 (where she scored 73% correct vs. 100% correct in L1), PKhad difficulties determining if the word she had just repeated was a real word or a non-word inEnglish. Of the eight errors, three involved real words (jar, lice, brew) and five were non-words(goom, chetty, rop, flup, sollick).

From PK’s performance on the verbal auditory discrimination subtests, we can concludethat her understanding in L1 was near normal but some difficulties persisted in L2, particu-larly at the levels of lexical semantics, syntax and phonological processing. When we talliedher correct responses across all comprehension tasks in L1 (94.2% correct) and L2 (87.1%correct), PK demonstrated a better recovery in L1 (see Figure 3).

Production. PK presented with fluent, well-articulated speech in both languages. She did,however, have a non-standard accent on her L2 derived from her L1, but this did not compro-mise her intelligibility in L2. She reported to now (post stroke) having a more pronouncedaccent on her L2, and her husband confirmed her observation. Her speech output was char-acterized by mild word-finding difficulties and characteristics such as hesitations and repeti-tions. She compensated well for word-finding difficulties in connected speech, particularly inL1, where she rarely had to pause or hesitate in conversation. In social conversation, herimpairments were barely discernible in either language and only becamemore apparent duringin-depth conversation in L2 but not L1. An example of her spontaneous output from the BATdescription task, based on a series of six pictures ‘The nest story’, is presented below.

L2: The nest story (italicized words ¼ errors)Aman and his wife went to a trip. They saw . . . they saw . . . a nest on top of the tree and the man triedto climb and get to see the little birds. But the tree crushed . . . not crushed . . . the tree was . . . but he felt. . . down off the tree and hurt his leg. The neighbours saw what happened and called to the hospital.But unfortly the little birds were dead . . . died . . . the little birds died.

On formal testing, PK showed difficulties in naming common objects (85% correct) in L2compared with L1 (100% correct). Of interest is the finding that she showed comparabledifficulties with automatic serial speech in both L1 and L2 where she was unable to name allthe days of the week or months of the year in the correct order. She showed no difficulties incounting from 1 to 25 in either language. Also, she demonstrated no difficulties repeatingwords and (in this case, nonsense) non-words in either language.

This said, PK did show a breakdown in word production, ranging from mild to severe,when required to process either semantic or morphological information related to a wordform in L2; this was not the case in L1. Specifically, at the semantic level, she showed amoderate impairment in (1) accessing and retrieving words in particular semantic categoriesand (2) producing semantic opposites. For the former, she was unable to eliminate the odd

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word in a series based on semantic category/information (e.g. blackbird, sardine, pigeon, eagle),where she scored 60% correct for L2 but had no such difficulties in L1 (100%). Likewise, PKwas unable to provide a word with the opposite meaning to the target word (e.g. target true!lied, targetwide! black, target high! small) in L2 (70% correct in L2 comparedwith 100% inL1). Her errors reveal a similar pattern to those identified in comprehension – mainly abreakdown at the level of lexical semantics, morphology and the phonological word form(e.g. wide was presumably interpreted as white, hence the response black as a semanticopposite). When we tallied her correct responses across all semantic tasks in L1 (98.0%correct) and L2 (79.6% correct), PK demonstrated a better recovery in L1 (see Figure 2).

PK also showed moderate difficulties on the derivational morphology subtest in L2 (70%correct) but not inL1 (100%correct). Shehaddifficulties applyingmorphological rules to converta heardword into an adjective (e.g. target silence! sile . . ., targetnobility! no response, target youth! no response), because of either lack of or partial representations in the lexicon. In fact, her mostsevere difficulties were in formulating morphological opposites in L2 (30% correct), where sheneeded to supply the prefix to make a word opposite in meaning to the target word (e.g. targetvisible! invisible). In L1, she scored within the normal limits on this task (80% correct).

Based on the results from the two morphological subtests, we conclude that derivationalmorphology presents as a problematic domain particularly in L2. When we tallied her correctresponses across all morphology tasks in L1 (94.7% correct) and L2 (71.1% correct), PKdemonstrated a better recovery of morphology in L1 (see Figure 2).

Reading. PK presented with mild difficulties reading words and sentences (aloud) in L2(see Table II). Her error on the L2 word-reading list was reading the target word bear as beer.On reading 2 of the 10 sentences, she made the following errors: (1) target ‘The boy holds thegirl.’ ! ‘The boy hands the girl.’ and (2) target ‘It’s the truck that pulls the car.’ ! ‘It’s thetruck that pulls the cat.’ We cautiously suggest that PK presents with symptoms of acquireddyslexia characterized by visual errors of the target words in L2, but more in-depth assess-ment is warranted. She had no difficulties with the reading tasks in L1 (at ceiling). Likewise,she demonstrated no difficulties in reading formeaning (reading comprehension) in either L1or L2.Whenwe tallied her correct responses across all reading tasks in L1 (100% correct) andL2 (91.1% correct), PK demonstrated a better recovery in L1 (see Figure 3).

Writing.PKdemonstrated no difficulties copying words and sentences in either language. Shedid, however, show non-comparable difficulties in L1 and L2 in dictation for both words (60%correct in L1, 40% correct in L2) and sentences (60% correct in both languages). However,analysis of her spelling errors revealed different strategies for L1 and L2 based on the ortho-graphic characteristics of each language (described in the Discussion section). For the former,she made phonological–orthographic errors that are phonologically plausible alternatives butincorrect in terms of word-specific orthography; for the latter, her errors were based on followingthe grapheme–phonemecorrespondence rules of Englishwhile spelling irregularwords. She alsodemonstrated an interference effect: her spelling of the vowel /u/ in L2was influenced by the waythe vowel is spelt in L1. We tentatively suggest that PK presents with symptoms of acquireddysgraphia in L1 andL2, but further testing is required. Examples of her written (spelling) errorsare presented in Table III. When we tallied her correct responses across all writing tasks in L1(73.3%correct) andL2 (66.6%correct), PKdemonstrated abetter recovery inL1 (seeFigure 3).

Specific language pair test: Greek–English

The specific aim of Part C of the BAT is to determine if one language shows a better recoverythan the other – and if so, which one. This evaluation is based on three skills: the individual’s

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ability to (1) recognize words in either language, (2) translate words and sentences from onelanguage into the other and (3) judge sentences for their grammatical acceptability in bothlanguages. This subtest of the BAT was administered to PK in one session upon completionof the language-specific tests (Part B), as stipulated by the BATmanual, 9 months post onset.

This subsection of the BAT is equivalent only for the given pair of languages (Greek–Englishin this case) and not across other language pairs. For the word recognition items, our patientshowed no difficulties matching words (nouns) for meaning from L1 to L2 and for the reverse.In contrast, she demonstrated moderate difficulties translating from L1 to L2 both concretewords (60% correct) and abstract words (40% correct). For concrete words, her (two) errorswere semantic paraphasias (L1 target αυτι ‘ear’! eye, L1 targetβαλιτσα ‘suitcase’! bag) and for(two) abstract words she made morphological errors (L1 target ασχημια ‘ugliness’ ! ugly, L1target λυπη ‘sadness’! sad) and a semantic error (L1 target πρoσoχη ‘attention’! take care).For the reverse pairs (from L2 to L1), she had difficulties with (three) abstract words only. Theerror analysis revealed (two) semantic paraphasias (L2 joy! απολαυση ‘gratification’ instead ofχαρα, L2 fright! τρομoς ‘terror’ instead of fοβoς) and one don’t know-response (L2 hatred).

Similarly, on the translation of sentences task, she showed comparable difficulties in bothlanguages with a slightly worse performance translating from L1 to L2 (40% correct vs. 60%correct). For the latter, she showed semantic paraphasias in her L2 responses (beer glass !wine bottle, baker! grocer) and errors with prepositions (in the summer! at the summer, on the10th ofMarch! at the 10th ofMarch). She also showed semantic paraphasias when translatingsentences from L2 to L1 (bottle ‘μπoυκαλι’ ! πoτηρι ‘glass’, the grocer ‘o μαναβης’ !σoυπερμαρκετ ‘supermarket’, 8th/eighth ‘oχτω’ ! δεκαoχτω ‘18th/eighteenth’). Finally, onthe grammaticality judgement task, PK’s performance on judging sentences in L1 as gram-matically (in)correct and later producing the ungrammatical ones as grammatically soundwas at ceiling. For L2, she made one error on judgement and as a consequence correction.She judged the sentence ‘The soldier asked a glass of water’ to be grammatically correct. PK’sraw scores on Part C of the BAT are presented in Table IV.

Discussion

We will use the results from the BAT to elaborate on three key areas in our discussion of thisresearch: (1) recovery patterns across languages for each linguistic domain, (2) residual lan-guage deficits and what they reveal and (3) issues pertaining to rehabilitation – in particular,linguistic and cognitive skills necessary for our participant’s return to teaching ESL.

Table III. Examples of PK’s written naming error responses.

Target word/sentence Written response

L1 L1νημα ‘cotton thread’ νιμαμυδι ‘oyster’ μειδηO αντρας φιλιεται απο τoν σκυλo.‘The man is being kissed by the dog.’

O αντραν φυλιεται απο τoν σκυλo

L2 L2Glue glouStick stikChin chenThe boy does not push the car The boy does not poush the car

Note: Boldface indicates spelling errors.

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Recovery patterns

Our results clearly demonstrate that bilingual individuals with aphasia do not necessarilymanifest the same linguistic deficits with the same degree of severity in both languages after asingle focal lesion (stroke) of the left hemisphere. As in other areas of aphasia research wherethere is a predominance of single-case design in the form of individual case studies, we baseour finding on the results of one person. We take heart in formulations such as the one madeby Paradis (2004: 88) that ‘[a] single case does not tell us how the brain of a bilingual works,but it does tell us what can happen.’

When we collapsed PK’s correct responses across linguistic levels (Figure 2) and skills(Figure 3) and compared results between Greek (L1) and English (L2) using non-parametricstatistics (Wilcoxon, 1945), there was a significant difference between languages with Greek(L1), the better recovered language for both linguistic levels, z ¼ –2.37, p ¼ 0.018 andlinguistic skills, z ¼ –2.02, p ¼ 0.043.

Comprehension and spoken output. Our participant’s recovery pattern in the domains ofcomprehension and expressive abilities revealed more difficulties in L2 compared with L1.Notmuch has been reported in the bilingual aphasia research on differential recovery patternsin comprehension, as recovery of spoken language abilities usually dominates (Lorenzen andMurray, 2008). No single factor has been identified so far to explain the recovery pattern –

instead, a wide array of factors come into play including age (neuroplasticity), premorbidproficiency, context of acquisition and type of bilingualism (Paradis, 1977). For PK, the roleand outcome of language therapy may be attributed to her better performance in L1. Thediagnosis of her language abilities at the acute phase when she began to receive speech andlanguage therapy in Greek was not made available to us. Only from PK’s performance on theBAT can we gauge the kind of structures targeted in therapy (e.g. comprehension tasks fromsingle words to paragraph level, picture naming tasks and word-finding tasks), the duration ofthe therapy (3 months) and the intensity of the therapy (1 day per week). She also reportedbeing very motivated to improve her Greek to communicate with her children and assist themwith their homework as well as to return to teaching and the school environment. Overall, ourfindings are in line with other reports in the literature of a non-parallel recovery with a greaterimpairment in L2, as reported by Fabbro (2001) for (20% of) bilingual Italian–Friulianspeakers on the BAT.

Table IV. PK’s raw scores on Part C of the BAT.

Scores by section L1 ! L2 L2 ! L1 L1 L2 Total

Word recognition 5 5 – – 5Translation of concrete words 3 5 – – 5Translation of abstract words 2 2 – – 5Translation of sentences 2 3 – – 6Grammaticality judgement – – 14 12 14Scores by linguistic level and skillMorphosyntax 16 15 – – 20Lexicon 10 12 – – 15Translation 12 15 – – 21

Grammatical judgement 14 12 – – 14

Note: Italicized numbers indicate responses that fall below the normal range.

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Reading and writing. It is well documented that the orthographic structure of a particularlanguage is of paramount importance in the manifestations of dyslexic and dysgraphicsymptoms (McNeil and Tseng, 2005), subsequent to aphasia onset. The more regular theorthographic structure of a language, the lower the need to rely on orthographic knowledge(stored word forms) to access the correct reading/writing of a word. In this case of languagepair, with two different orthographies (namely, transparent Greek vs. non-transparentEnglish), reading and writing relies on language-specific approaches: a direct, lexical strat-egy for English and a sub-lexical strategy for Greek (e.g. phoneme-to-grapheme conver-sion).Our participant demonstratedmild difficulties reading in L2 but no such difficulties inL1. Thus we propose that the recovery of reading reveals a non-parallel pattern.With regardto writing, she demonstrated comparable difficulties in both languages indicating that, atleast in this domain, recovery is not significantly diverging. An explanation for the differencein L1 performance between reading and writing on the one hand and the comparableperformance in writing between L1 and L2 on the other may lie in the fact that Greek isless transparent for writing (than for reading only), because the same phoneme mightcorrespond to different graphemes (historical orthography). This asymmetry in thephoneme-to-graphememapping between reading and writing in Greekmay lead to a similarperformance in the writing section of the test between L1 and L2 because both Greek andEnglish have non-transparent orthographies but differences between the reading and writ-ing sections of the test in L1.

Translation abilities. As is the case with all linguistic tasks, different impairments andrecovery patterns related to translation abilities can also manifest in bilingual individualswith aphasia (Paradis, 2004). Translation skills incorporate additional non-linguistic cogni-tive (or executive function) skills, such as switching (languages) and inhibition (not allowinginterference from the other language), to carry out the task. PK demonstrated an equal andsignificant inability to translate from either language to the other for abstract words andsentences. The effect was more evident in translation from L1 to L2, because concrete wordswere also involved at this level. We interpret her translation deficits as part of a largersemantic–conceptual deficit affecting word search and retrieval, particularly in L2. Ourfindings tie in with suggestions that links between a bilingual’s words and concepts may beasymmetrical (i.e. some links between the two lexicons or conceptual storage are stronger orweaker than others) and the differences in proficiency (post stroke) could be the cause ofdirectional differences (see Kroll and Stewart, 1994). Alternatively, PK’s cognitive abilitieswarrant further investigation to determine if the language behaviours are a by-product ofcognitive deficits.

Residual language deficits

Residual language-dependent deficits vary significantly across linguistic structures and levelswith bilingual aphasia. According to Paradis (1987), it is the structure of the particularlanguage system in question that determines how the language system can break down, andat what levels it does so. For our participant, PK, greater language impairments remain in L2compared with L1, particularly in the areas of morphosyntax, and especially for derivationalmorphology, despite English being a significantly less morphologically complex languagethan Greek. Specifically, applying morphological rules to form opposites or different wordcategories were areas with significant difficulties, such as deriving adjectives from nouns. Weattribute her deficits in this area to two different underlying mechanisms affecting herperformance in L2:

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(1) persistent difficulties with lexical semantic abilities for words no longer available oronly partially activated in the participant’s mental lexicon due to damage to semanticrepresentations;

(2) partial or absent word-rule formation abilities.

In the area of lexical semantics (both comprehension and production), our participant, PK,demonstrated more semantic paraphasias in L2 compared with L1. In fact, semantic para-phasias were the only type observed. This further confirms our interpretation of a deficit at thelevel of conceptual semantics or the link between semantics and the word form. PK demon-strated no paraphasic examples unique to bilingualism, such as interlanguage interference. Itis possible that potential difficulties with morphosyntax in L1 were targeted in languagetherapy, hence her better performance in L1 and absence of transfer effects evident in L2.Her larger vocabulary in L1 may be attributed further to her reading books, even grammarbooks, to regain her language skills to return to work and guide her children with theirhomework, a role she had taken before her illness.

For spelling, mild to moderate difficulties remain in each language, perhaps linked to thefrequency of the word form, and the language-specific spelling strategy required her to writethe word. As for reading, PK demonstrates a mild disturbance in L2 for reading aloud.Moreover, she showed evidence of acquired dyscalculia in L1 and L2, where she haddifficulty carrying out mental arithmetic functions, that is, basic mathematical operations ofaddition, subtraction, multiplication and division. Her calculation ability was not tested inwriting (not part of the BAT) to rule out loss of knowledge of the operations. It is possible thatworking memory impairments might compromise this function, which is heavily dependenton working memory functions – but working memory was not formally tested. Given heracademic qualifications and motivation to return to teaching, all areas with residual languagedeficits warrant further investigation to identify specific therapeutic goals for each language.

In sum, our results from Part B of the English version of the BAT for PK supportexplanations in Paradis (2004) that late bilinguals, particularly when L2 was formally taught,rely more on declarative metalinguistic knowledge for lexical and grammatical tasks. Damageto declarative memory affects their performance in the later acquired language. In fact, PK’snon-parallel recovery patterns across linguistic domains may be found in the mechanismsof (dis)inhibition affecting the neural substrate subserving language competence (Paradis,2004: 54).

Issues pertaining to rehabilitation

To return to teaching ESL, our participant requires speech and language therapy targeted toher linguistic needs in L2 in the following domains: comprehension, expression, reading,writing, arithmetic and serial (automatic) speech. Linguistic levels affected include thelexicon, semantics, syntax, morphology and phonology. For example, therapy targeted toremediate poor lexical access/vocabulary gaps could include strategies such as repair andrestore and/or relearn (Kohnert, 2008). Information regarding the extent of PK’s abilities inEnglish only came about because she was tested in her second language for the first time.However, PK was aware that her English was more impaired than her Greek. Furthermore,her reassessment in Greek several months following treatment revealed persisting languagedifficulties (e.g. poor comprehension of complex commands, dyscalculia, etc.) in the chronicrecovery phase. She continues to require speech and language therapy in L1, not only targetedat similar domains and levels as before but also now across different modalities.

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Both languages need to be included in therapy in the future to ensure that PK utilizes allpossible communicative strategies available to her and, most importantly, that the rehabilita-tion process includes goals addressing vocation. Concerning the suitability of the Greekversion of the BAT for an understudied dialect such as Cypriot Greek (see our qualificationsabove), we postpone our assessment; rather than providing suggestions for potential futureadaptations, we should wait until more data are available.

Conclusion

The assessment of individuals suffering from aphasia in two (or more) languages is a multi-faceted task. It is essential to evaluate and document the individual’s recovery patterns afterthe onset of aphasia within and across languages to target therapy to specific loci of breakdownfor each language system. The BAT is an efficient tool with equivalent tasks to discriminatelanguage deficits in two (or more) languages.

For our research purposes, we defined bi- or multilingual speakers as those who speak two ormore languages regularly in daily life without, necessarily, perfect knowledge of all (Grosjean,1994). In our work, dialects should ideally be subsumed under the term language, certainly foraspects of language assessment and especially when there are serious differences to the standardvariety across a number of linguistic levels — be it referred to as diglossia, bidalectism, orbilingualism, as is often the case for understudied varieties (for additional discussion, especiallywith reference to this case of Cyprus, see Grohmann, in press). This said, cerebral representa-tion based on structural distance between standard and dialectal varieties is still under debate(Paradis, 1995). Based on the assumptions made by Paradis (2004), non-standard dialectslacking a conventional written form are acquired implicitly and used throughout life withoutmuch metalinguistic awareness on the part of the native speaker. In many cases, speakers ofsuch varieties learn a second language, often a related standard language in school. Somemetalinguistic knowledge of the standard language, the language of instruction, is explicitlytaught in school as part of the regular curriculum.

As aphasia is caused by disruption of procedural memory (linguistic competence), subse-quent to a focal cortical lesion, metalinguistic knowledge, being subserved by an altogetherdifferent neural system, should remain available to the speaker. Thus, in the case of a bidialectalspeaker, the amount of metalinguistic knowledge about the standard variety used in school asthe medium of instruction is likely to be greater than that of the native dialect (Hamers andBlanc, 2000, e.g., offer pertinent discussion; for a very interesting recent discussion in terms ofacquisition, see especially Siegel, 2010). Our speaker falls into this category, having grown upwith Cypriot Greek and acquired StandardModern Greek through schooling from a very earlyage. As all formal and educational situations require the use of StandardModernGreek, and asthe Greek version of the BAT is currently only available for the standard variety, we investigateour participants as anL1 speaker ofGreekwithEnglish as L2. Futureworkwill shed light on thequestion whether we should have considered PK to be an L1 speaker of Cypriot Greek instead,with (Standard Modern) Greek and English as L2 and L3, respectively.

We close this article with the observation that, although the global trend towards bilingualor multilingual populations is reflected in the specific sociolinguistic situation on the island ofCyprus, speech pathology is predominantly amonolingual-speaking profession on an increas-ing multicultural island. This is so despite the fact that, to date, all practicing speech andlanguage therapists have received professional academic education and training outside ofCyprus. Practitioners have received their training in a large variety of countries – in fact, 10different countries for over 250 registered speech pathologists (such as Bulgaria, Romania,

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the United Kingdom, to name a few). This has two negative connotations: (1) most speechpathologists did not get acquainted with the properties of the Greek language as part of theirsyllabus and (2) most did not work with Greek-speaking clients during their supervisedclinical practicum before returning to Cyprus; on both counts, we add the serious knowledgegap for Cypriot Greek, as obvious as it is sad, which is something we will address in futureworks. As such, clinicians have insufficient linguistic expertise on which to base their inter-ventions that in turn impacts on language therapy (Proios, 2008) and service provision to(bilingual) clients with aphasia (Kambanaros, 2010).

In the case of our participant PK, a younger-in-age stroke victim, recovery of her standardlanguage, Greek (which should possibly be regarded as L2 rather than L1), was of vitalimportance for her return to work. Nine months post onset (September 2010), PK did returnto work. By choice, she is currently teaching grade two primary school children (7–8 years ofage) in Greek, but not in English, because of her (near) complete recovery in Greek and thesmaller linguistic demands of theGreek curriculum for this age group.Her youngest daughteris also a pupil in her class.

Acknowledgements

We thank first and foremost PK for her relentless patience and hospitality in her activeparticipation for the purpose of this study. The comments from two anonymous reviewershelped us, so we hope, improve this paper further.

Declaration of interest: The authors report no declarations of interest. The research waspartially funded by the Gen-CHILD Project awarded to the second-named author (Universityof Cyprus, grant no. 8037-61017).

Notes

1. Incidentally, the country where the case study presented in this article was carried out, the Republic of Cyprus,falls into the ‘not all’ group. Unfortunately, as we will lay out below, the unofficial Cypriot Greek variety could notbe tested, yet we will allude to some interesting issues for further research (see also the Conclusion section). It islinguistically understudied which carries over to issues of language assessment.

2. See Paradis (1995) for an in-depth discussion on all points raised here; we will return to some aspects within ouroutlook beyond our single-case study in the Conclusion section of this contribution.

3. Ultimately, our research is drivenbydetermining suitability of theBATfordialectal variationsofModernGreek, a goalthat we consider of high theoretical and clinical importance; to learn more about our ongoing efforts on (a)typicallanguage development, which also includes acquired impairments, see also the website of the Cyprus AcquisitionTeam (http://www.research.biolinguistics.eu/CAT). At this point, however, we cannot say too much about thesuitability of the BAT for non-standard varieties, such as Cypriot Greek, because we do not even know its suitabilityfor the standard variety (see also theConclusion section). Indeed, this is the first study to administer thecompleteBAT(i.e. Parts A–C) to a bilingual Greek speaker, that is, the first application of the BAT with its intended use for Greek.

4. There is a working version of the Boston Diagnostic Aphasia Examination for diagnostic and research purposes(Papathanasiou, Papadimitriou, Gavrilou, and Mixou, 2008).

5. That is, the variety of Greek adapted in the BAT, which linguists would call StandardModernGreek (to the extentthat it is indeed the same in Cyprus as it is in Greece; see also Arvaniti, 2006; Grohmann, in press).

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