Limited English Proficient Children Research Articles

Bias, Prejudice, Discrimination, Racism, and Social Determinants: The Impact on the Health and Well-Being of Latino Children and Youth

This narrative review focuses on the impact of bias, prejudice, discrimination, racism (BPDR), social determinants of health, and structural racism on Latino children’s health and well-being. The race/ethnicity, country of origin, immigrant/generational status, limited English proficiency (LEP), acculturation level, and social class of Latino children and their parents can heighten or modify the impact of BPDR. These differences have been shown to affect BPDR among Latino adults and presumably for their children. Surveys of Latino adolescents reveal that 60% have experienced discrimination, with first- and second-generation teens having a higher prevalence. These experiences are magnified by adverse social determinants/structural racism. BPDR can impact Latino children prenatally through adolescence. Bias involving neonatal, primary, and inpatient pediatric services has been reported. In 2021, Latino children were 19% less likely to complete preventive care, and 32% of LEP children had no medical home. School-age Latino children experience system inequities associated with chronic physical and mental health conditions. BPDR is also seen in educational performance but can be buffered by a strong racial/ethnic self-identity. To address BPDR/structural racism for Latino children, we suggest pediatricians: 1) increase the Latino child-health workforce to address BPDR internally and externally, 2) advocate for data collection on and monitoring of Latino children’s disparities and racism metrics in pediatric services, to improve quality of care for Latino children and their families, and 3) advocate for child health equity. Together, these steps will help eliminate BPDR for Latino children and ensure they obtain their full potential.

Evaluation of Limited English Proficiency in the Management and Outcomes of Appendicitis in Children

IntroductionAppendectomies are one of the most common pediatric surgical procedures. Limited English proficiency (LEP) may lead to disparities in health outcomes between English-proficient and LEP patients. This study assesses the association between LEP and postoperative outcomes in pediatric appendectomy. MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program–Pediatric database from 2010 to 2023 under 18 y of age undergoing appendectomy at our institution. LEP was defined as the need for an interpreter. Primary outcomes were postoperative complications, length of stay (LOS), and postoperative emergency department (ED) visits within 30 d of discharge. Multivariable analyses were performed. ResultsOne thousand one hundred forty three children with appendicitis were identified, with 208 (18.2%) LEP and 935 (81.8%) English-proficient patients. LEP children were more likely to present with complicated appendicitis (42.8% versus 25.5%, P < 0.0001) and sepsis (34.1% versus 21.6%, P = 0.0003). LEP patients experience more serious (8.6% versus 3.9%, P = 0.02), overall complications (10.1% versus 5.5%, P = 0.006), and organ/surgical space site infections (8.2% versus 3.3%, P = 0.003). On multivariable analysis controlling for ethnicity and factors associated with complicated presentation, LEP was associated with increased postoperative ED visits (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] = 1.40-4.39), but not LOS (aOR 1.86, 95% CI = 0.87-3.97) or complications (aOR 1.76, 95% CI = 0.79-4.00). ConclusionsLEP is independently associated with increased postoperative ED visits. Higher rates of complications and longer LOS may be related to increased complicated appendicitis at presentation. The role of cultural preferences and other social determinants of health that contribute to these disparities needs more investigation.

Limited English Proficiency can Negatively Impact Disease/Treatment in Children With Cancer Compared to Those Who are English Proficient-an Institutional Study

BackgroundIn 2013, 25.5 million people in the United States self-identified as having limited English proficiency (LEP). LEP in adults has been associated with longer hospital stays, increased adverse events, increased emergency room visits, and decreased understanding of medications prescribed. This study aims to define the relationship between LEP and outcomes in a pediatric oncologic population. MethodsWe performed a matched case-control study utilizing data from our institutional cancer database (children </ = 18, 2012-2021). LEP families were matched by disease and stage with English proficient (EP) families. Descriptive, univariate, and bivariate analysis were performed. ResultsTwenty-four LEP children were identified and matched with 77 EP children. LEP children represented 11 languages, with the most common being Spanish (42%). Statistical regression demonstrated a clinically significant trend for LEP children to have an increased mean number of unexpected hospital admissions (p = 0.04), increased number of clinic cancellations (n = 0.003), and increased emergency department visits (p = 0.05). LEP children were more likely to have Medicaid than commercial insurance (p < 0.001). There was no difference in 2-year event free or overall survival. ConclusionIn our study cohort, LEP families are at risk for more negative treatment experiences than EP families. Further studies are needed to delineate specific causes and interventions. Type of StudyRetrospective comparative cohort study. Level of EvidenceLevel III.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency.

Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families. In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings. We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters. Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

Inpatient Communication Barriers and Drivers When Caring for Limited English Proficiency Children.

Achieving effective communication between medical providers and families with limited English proficiency (LEP) in the hospital is difficult. Our objective was to identify barriers to and drivers of effective interpreter service use when caring for hospitalized LEP children from the perspectives of pediatric medical providers and interpreters. We used Group Level Assessment (GLA), a structured qualitative participatory method that allows participants to directly produce and analyze data in an interactive group session. Participants from a single academic children's hospital generated individual responses to prompts and identified themes and relevant action items. Themes were further consolidated by our research team and verified by stakeholder groups. Four GLA sessions were conducted including 64 participants: hospital medicine physicians and pediatric residents (56%), inpatient nursing staff (16%), and interpreter services staff (28%). Barriers identified included: (1) difficulties accessing interpreter services; (2) uncertainty in communication with LEP families; (3) unclear and inconsistent expectations and roles of team members; and (4) unmet family engagement expectations. Drivers of effective communication were: (1) utilizing a team-based approach between medical providers and interpreters; (2) understanding the role of cultural context in providing culturally effective care; (3) practicing empathy for patients and families; and (4) using effective family-centered communication strategies. Participants identified unique barriers and drivers that impact communication with LEP patients and their families during hospitalization. Future directions include exploring the perspective of LEP families and utilizing team-based and family-centered communication strategies to standardize and improve communication practices.

Professional Interpreter Use and Discharge Communication in the Pediatric Emergency Department

ObjectiveFamilies with limited English proficiency (LEP) experience communication barriers and are at risk for adverse events after discharge from the pediatric emergency department (ED). We sought to describe the characteristics of ED discharge communication for LEP families and to assess whether the use of a professional interpreter was associated with provider communication quality during ED discharge. MethodsTranscripts of video-recorded ED visits for Spanish-speaking LEP families were obtained from a larger study comparing professional interpretation modalities in a freestanding children's hospital. Caregiver-provider communication interactions that included discharge education were analyzed for content and for the techniques that providers used to assess caregiver comprehension. Regression analysis was used to assess for an association between professional interpreter use and discharge education content or assessment of caregiver comprehension. ResultsWe analyzed 101 discharge communication interactions from 47 LEP patient visits; 31% of communications did not use professional interpretation. Although most patients (70%) received complete discharge education content, only 65% received instructions on medication dosing, and only 55% were given return precautions. Thirteen percent of the patient visits included an open-ended question to assess caregiver comprehension, and none included teach-back. Professional interpreter use was associated with greater odds of complete discharge education content (odds ratio [OR], 7.1; 95% confidence interval [CI], 1.4–37.0) and high-quality provider assessment of caregiver comprehension (OR, 6.1; 95% CI, 2.3–15.9). ConclusionsProfessional interpreter use is associated with superior provider discharge communication behaviors. This study identifies clear areas for improving discharge communication, which may improve safety and outcomes for LEP children discharged from the ED.

Informing physician strategies to overcome language barriers in encounters with pediatric patients

ObjectivesTo describe physician perceptions of differences in limited English proficient (LEP) pediatric encounters and the behavioral adaptations they make to provide quality care to LEP pediatric patients. MethodsWe conducted 30min, semi-structured interviews with 6 family physicians and 5 pediatricians in one health system. Audiotapes from each interview were transcribed verbatim then coded using content analysis. ResultsMultiple aspects of the LEP pediatric encounter were perceived by physicians as different from other encounters: trust and relationship between physician and LEP child/child’s family, continuity of care, encounter’s structure and flow, patient assessment, and communication barriers. Within each of these themes, physicians identified how they adapt their behavior to improve the quality of care provided to LEP children and families. ConclusionsPhysicians’ made both positive and negative adaptations in LEP pediatric encounters that may impact the quality of care provided to these patients. Practice implicationsBy identification of specific positive and negative behavioral adaptations, this study emphasizes intervention targets, such as demonstrating interest in an LEP pediatric patient’s family story and individuality and using common niceties in conversations with LEP children.

Does the Value of Dynamic Assessment in Predicting End-of-First-Grade Mathematics Performance Differ as a Function of English Language Proficiency?

The purpose of this study was to assess the added value of dynamic assessment (DA) beyond more conventional static measures for predicting individual differences in year-end 1st-grade calculation (CA) and word-problem (WP) performance, as a function of limited English proficiency (LEP) status. At the start of 1st grade, students (129 LEP; 163 non-LEP) were assessed on a brief static mathematics test, an extended static mathematics test, static tests of domain-general abilities associated with CAs and WPs (vocabulary; reasoning), and DA. Near end of 1st grade, they were assessed on CA and WP. Regression analyses indicated that the value of the predictor depends on the predicted outcome and LEP status. In predicting CAs, the extended mathematics test and DA uniquely explained variance for LEP children, with stronger predictive value for the extended mathematics test; for non-LEP children, the extended mathematics test was the only significant predictor. However, in predicting WPs, only DA and vocabulary were uniquely predictive for LEP children, with stronger value for DA; for non-LEP children, the extended mathematics test and DA were comparably uniquely predictive. Neither the brief static mathematics test nor reasoning was significant in predicting either outcome. The potential value of a gated screening process, using an extended mathematics assessment to predict CAs and using DA to predict WPs, is discussed.

Evaluation of a quality improvement intervention to increase use of telephonic interpretation.

Language barriers are associated with poor health care outcomes, and barriers exist for timely in-person interpretation. Although available on-demand, telephonic interpretation remains underutilized. This study evaluates whether a quality improvement (QI) intervention was associated with rates of interpretation and parent-reported language service use at a children's hospital. The QI intervention was developed by a multidisciplinary team and included provider education, electronic alerts, standardized dual-handset telephones, and 1-touch dialing in all hospital rooms. Interpreter use was tracked for 12 months before, 5 months during, and 12 months after the intervention. Weekly rates of interpretation per limited English proficient (LEP) patient-day were evaluated by using segmented linear regression. LEP parents were surveyed about professional interpretation and delays in care. Responses before, during, and after the intervention were compared by using the χ(2) test for trend. Telephonic interpretation rates increased by 53% after the intervention (baseline 0.38 per patient-day, increased 0.20 [0.13-0.28]). Overall (telephonic and in-person) interpretation increased by 54% (baseline 0.96, increased by 0.51 [0.38-0.64]). Parent-reported interpreter use improved, including more frequent use of professional interpreters (53.3% before, 71.8% during, 69.3% after, P trend = .001), less frequent use of ad hoc interpreters (52.4% before, 38.1% during, 41.4% after, P trend = .03), and fewer interpretation-related delays in care (13.3% before, 7.9% during, 6.0% after, P trend = .01). This QI intervention was associated with increased telephonic interpreter use and improved parent-reported use of professional language services. This is a promising approach to deliver safe, timely, and equitable care for the growing population of LEP children and families.

Primary care for limited English-speaking patients and parents.

The number of persons in the United States who have a primary language other than English has been steadily increasing for decades. The latest census information reveals that citizens with limited English proficiency (LEP) represent approximately 16% of the population. The inability to effectively communicate creates stark challenges in the delivery and receipt of health care. Language discordance in the healthcare setting has been firmly established as a source for health disparities among LEP patients and families. Poorer health outcomes are seen across the healthcare setting for LEP patients and children of LEP parents. Scientific literature review, scholarly databases, Internet sites. There are various systems and methods that can be implemented in order to help improve health outcomes for LEP patients. There are benefits and challenges to each of the methods available for LEP patients and their providers. Improvements must be made on numerous levels including in clinical settings, in training curricula, and system wide. The risks associated with decreased quality of communication between patient and provider merit an earnest consideration of the methods available for LEP patients and implementing some of these services for those patients.

English proficiency and postoperative pain treatment in hospitalized children

Adequate pain assessment requires good communication between care providers and patients. Limited English proficiency (LEP) is a known risk factor for poor health outcomes. We conducted a retrospective, matched, case-control study to evaluate the association between English proficiency and adequacy of pain assessment and treatment in hospitalized pediatric patients. LEP children 0-18 years of age who underwent surgery were matched with English Proficient (EP) patients by age, type of surgery and date of discharge.

The Flawed Requirements for Limited English Proficient Children of the No Child Left behind Act

The Flawed Requirements for Limited English Proficient Children of the No Child Left behind Act

State School Funding Policies and Limited English Proficient Students

This article presents an overview of state funding policies for serving Limited English Proficient (LEP) students and analysis of aid allocation practices across the states using data from the National Center for Education Statistics Common Core of Data. The major finding of this study is that state efforts to help local districts are often poorly conceived and/or applied, and often inadequate. We conclude with three policy recommendations for enhancing the present knowledge base, including the need for (a) expanded national, state, and local awareness of policies and practices across the states regarding limited English proficient (LEP) children, and improved monitoring of the effectiveness of those policies and practices toward achieving specific objectives; (b) empirically derived cost estimates of opportunities for LEP children; and (c) a set of frameworks for developing and adapting funding policies to various state contexts aimed toward achieving the goal of adequate services for LEP children.

Speculation and Conjecture

Mr. Krashen disputes the analysis of Richard Innes regarding the impact of whole-language instruction on California reading scores. IN HIS response to my June 2002 article, Richard Innes presents two sets of criticisms, one related to CAP scores and one to NAEP scores. CAP Scores Innes maintains that CAP scores showed an improvement before was introduced in California and a decline after was introduced. The improvement he refers to is the increase in CAP scores for third-graders from 268 to 282 between 1984 and 1987. This, Innes maintains, contradicts the claims that there is no clear pattern in CAP scores and that California's reading problem existed well before was allegedly introduced. The decline he refers to is the drop in scores from 282 to 275 between 1988 and 1990. According to Innes, this change reflects the impact of language. The problem with this analysis is that the recommendations of the 1987 Language Arts Framework were not implemented until much later. California districts did not have textbooks that were consistent with the 1987 framework until the 1989-90 school year,1 which means that the CAP scores presented in my original article were only minimally influenced by the framework committee. If whole language (actually literature-based instruction) had been solidly in place throughout California in the fall of 1989 those in grade 3 in 1990 would have had grade 2 and part of grade 3 under the new literature-based program, and those in grade 3 in 1989 would have had only part of grade 3 under the new program. What caused the increase in third-grade scores that Innes mentions? A look at the entire range of California CAP scores shows that they are part of a general increase that began when the CAP was introduced in California in 1979, not counting a 10-point drop in 1984-85 in grade 8 (Table 1). The increase is real, but two facts must be noted. 1. The increases are not large. The scores presented are scaled scores, with a range of 100 to 400. They are much smaller than percentiles. (The state average is considered to be 250. This is by definition the score that is achieved the first time the test is given.) 2. One expects gains in standardized tests. Research has shown that after new tests are introduced, test scores rise, which is why commercial tests need to be recalibrated every few years.2 Typical test-score inflation for third-grade reading scores ranges from .3 to 1.9 national percentile ranks per year,3 which is about what one sees in Table 1. (John Guthrie and his colleagues claim that this is not the cause of the increases seen in California. They point out that the CAP test does not consist of a small number of items, but is a matrix-sample type of test in which each individual student takes only a small subset of the total items; items vary for each student in the same classroom. This makes the test more resistant to cheating and direct teaching to the items in the test.4 Nevertheless, increasing familiarity with the test format and the kind of questions asked could contribute to test-score inflation.) What about the decline from 1988 to 1990? A look at Table 1 shows that this decline was present in grade 6 as well, making it even less likely that it was due to language, an approach generally used in the lower grades. If we are looking for candidates for the decline, they are easy to find.5 1. The number of children with limited English proficiency (LEP) in California rose dramatically after 1987. From 1984 to 1987 the number of LEP children rose from about 500,000 to 600,000, but from 1987 to 1990 it rose to 850,000, increasing to 1,150,000 in 1992. Thus, while the number of LEP students had been increasing before 1987, the rate jumped sharply after 1987. In California, a large percentage of those taking the NAEP have limited English proficiency, which has a clear effect on scores. …

The importance of cultural and linguistic issues in the emergency care of children.

Rapid growth in the diversity of the US population makes it increasingly likely that emergency clinicians will encounter greater numbers of patients from different cultures, but little is known about the importance of culture and language in the emergency care of children. To conduct a critical review and synthesis of published studies on culture and language in the emergency care of children. PubMed was used to perform a literature search (using 17 search terms) of all articles on culture, language, and the emergency care of children published in English or Spanish from 1966 to 1999. More than 2000 citations initially were identified; consensus review yielded 400 papers that were photocopied. A final database of 117 articles revealed the following: certain normative cultural values, such as the Navajo hozhooji (the importance of thinking and speaking positively), can have profound effects on informed consent and discussions of medical risk. For limited English proficient children and their families, studies document that medical interpreters frequently are not used, there is a lack of trained interpreters, there are more access barriers, and those who need but do not get interpreters have poor understanding of their diagnosis and treatment. Numerous folk illnesses, such as among Latinos, can affect care, because symptoms often overlap with important biomedical conditions, the first clinical contact may be with folk healers, and certain folk remedies are harmful or even fatal. Certain parent beliefs and practices can result in serious morbidity and fatalities (from lead poisoning, liver failure, and other causes), costly or unnecessary medical evaluations (eg, Fenugreek teas), and clinical findings easily confused with child abuse (eg, coining). Biased provider attitudes and practices can have profound clinical consequences, including ethnic disparities in prescriptions, analgesia, test ordering, sexual history taking, asthma care quality, and diagnostic evaluations. Failure to appreciate the importance of culture and language in pediatric emergencies can result in multiple adverse consequences, including difficulties with informed consent, miscommunication, inadequate understanding of diagnoses and treatment by families, dissatisfaction with care, preventable morbidity and mortality, unnecessary child abuse evaluations, lower quality of care, clinician bias, and ethnic disparities in prescriptions, analgesia, test ordering, and diagnostic evaluations.

A Meta-Analysis of the Rossell and Baker Review of Bilingual Education Research

In 1996, Christine Rossell and Keith Baker conducted a review of the literature on the effectiveness of bilingual education and concluded that the majority of 75 methodologically acceptable studies showed that bilingual education was not beneficial. This study re-examines their literature review to verify the Rossell and Baker list of methodologically acceptable studies. After identifying only 11 studies that actually meet the standards for being methodologically acceptable, this study aggregates the results of those studies by a technique known as meta-analysis. The conclusion of the meta-analysis is that the use of at least some native language in the instruction of limited English proficient children has moderate beneficial effects on those children relative to their being taught only in English.

Preparing Future Bilingual Special Educators: The Lessons We've Learned

The purpose of this paper is twofold. We describe the goals and curricular content of a teacher education program designed to prepare individuals to teach limited English proficient children with disabilities. As part of this description, we include a discussion of graduates' feedback regarding program strengths and weaknesses. Next, based on this feedback and our experiences as teacher educators in the program, we present critical features of a bilingual special education teacher preparation program. These features emphasize providing social and emotional support to teacher candidates, teaching them how to create culturally responsive classrooms, challenging students to re-think their beliefs about teaching and learning, expanding the notion of collaboration to include community services, and supporting graduates while they attempt to effect change in their classrooms and schools.

Ensenanzas en un Gimnasio: An Investigation of Modeling and Verbal Rehearsal on the Motor Performance of Hispanic Limited English Proficient Children

This study investigated the effects of modeling and verbal rehearsal on the motor performance of English-speaking and limited English proficient (LEP) children. Children (N = 64) in 4th-grade classes were randomly assigned to conditions in a 2 x 2 x 2 x 2 (Gender x Primary Language x Model Type x Rehearsal) factorial design. Boys and girls whose primary language was English or Spanish were assigned to either a verbal model or no-model condition as well as to a verbal rehearsal or no-rehearsal condition of the motor skills required to be performed. Analysis of variance revealed a significant Model Type x Primary Language interaction as well as a significant Rehearsal x Primary Language interaction. Follow-up analyses revealed that English-speaking children provided with a verbal rehearsal strategy recalled significantly more skills than English-speaking children in the no-rehearsal condition; for LEP children, there were no differences due to rehearsal. Moreover, LEP children presented with a verbal model recalled significantly more skills than LEP children in the no-model condition; for English-speaking children, there were no differences attributed to model type. These results indicate that effective modeling conditions that are provided with verbal cues in English are related to children's primary language.

Assessment and Intervention for Children With Limited English Proficiency and Language Disorders

The number of children with limited English proficiency (LEP) in U.S. public schools is growing dramatically. Speech-language pathologists increasingly receive referrals from classroom teachers for children with limited English proficiency who are struggling in school. The speech-language pathologists are frequently asked to determine if the children have language disorders that may be causing or contributing to their academic difficulties. Most speech-language pathologists are monolingual English speakers who have had little or no coursework or training related to the needs of LEP children. This article discusses practical, clinically applicable ideas for assessment and treatment of LEP children who are language impaired, and gives suggestions for distinguishing language differences from language disorders in children with limited English proficiency.

Serving Children With Limited English Proficiency in the Schools

A national survey of public school clinicians ( N =1,145) was conducted to assess these clinicians' services to limited English proficient (LEP) children. The main findings of the survey follow: 1. The ethnic group served most commonly by clinicians was Hispanic. 2. The type of treatment provided most frequently for LEP children was language treatment. 3. Ninety percent of the respondents did not speak a second language fluently enough to provide services in that language. 4. Approximately 76% of the respondents had no previous coursework or classes addressing services for LEP children. 5. Problems encountered most frequently by the respondents were the lack of appropriate assessment instruments and the inability to speak the languages of the children they served. In terms of continuing education topics, respondents were most interested in learning about assessment and treatment procedures for LEP children. Eighty-five percent of the respondents indicated that they felt the best service delivery model for the continuing education of LEP children was workshops offered by school districts. They also expressed interest in coursework offered by universities. Implications of the survey findings for the profession are discussed.