Turkish: Linguistic and Cultural Considerations for SLPs

in Multilingual Contexts
Seyhun Topbaş
Department of Speech and Language Therapy, Anadolu University
Turkey
Financial Disclosure: Seyhun Topbaş is a Professor and Faculty of Health Sciences at Anadolu
University.
Nonfinancial Disclosure: Seyhun Topbaş has no nonfinancial interests related to the content of
this article.

Abstract
Speech-language pathologists (SLPs) around the world are likely to provide clinical services
to Turkish speaking people with communication disorders. Most non-Turkish SLPs are not
fluent in Turkish as a second language to serve bilingual or minority clients. This paper
introduces the reader to basic information about the Turkish language and culture, followed
by considerations for clinicians working with Turkish-speaking clients and their families.

Turkish Speakers beyond Homeland

Turkish is the most widely spoken language in the European Union (EU) by approximately
5 million people, around 4 million of which live in Western European countries. Over 3 million
speakers of Turkish live in Germany and other northern European countries, Belgium, France,
Denmark, and England. Over a million live in Bulgaria, Macedonia, and Greece (Ministry of
Foreign Affairs, 2012). Turkish also has the largest number of speakers in a family of Turkic
languages spoken across Eastern Europe and Asia and is the third most widely spoken language in
the Middle East. It is estimated that approximately 150,000 speakers of Turkish live in Australia,
Japan, and far-east countries.
Turkish is a growing but under-studied United States language. There have been three
waves of immigration from Turkey to the United States; at the beginning of the 19th century,
after World War II, and in the late 1980s. Since then the number of people with Turkish ancestry
in the United States increased to 500,000 (U.S. Census Bureau, 2010). Today, Turkish Americans
live in all fifty states, although the largest concentrations are found in metropolitan areas such
as the State of New York, California, New Jersey, Florida, Texas, Virginia, Illinois, Massachusetts,
Pennsylvania, Maryland, and Washington D.C.
The percentage of Turkish clients comprising speech-language pathologists’ (SLP) caseloads
throughout the world is not known. There is a very limited number of Turkish SLPs who could
serve the Turkish community for any communication disorders. Thus, a large number of Turkish
individuals with communication disorders will receive SLP services from a non-Turkish speaking
SLP. This could create challenges in the assessment and the treatment of the individual.
In the United States or most EU countries, Turkish immigrants, who are mostly from rural
areas of Turkey, might carry the risk of being under-referred for speech and language disorders
(SLD) in their second language (L2). Usually, the criterion of limited communicative competence
in both languages is used for determining the presence of a language disorder. In grammatical
evaluations, a norm-referenced evaluation is also necessary (Bi-SLi, n.d.). Personal contacts with
SLP colleagues in the Netherlands, Germany, and Denmark emphasize the need of an evaluation
in the first language specifically in children with language impairments (LI/SLI) with unknown
aetiologies and in aphasia assessment and therapies.

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 Linguistic and Cultural Diversity in Turkey
Turkey, with its population of 77,323,892 (as of 2014), serves as a bridging country between
Europe and Asia including the Middle-East. It has been home to many ethnic, religious, and
linguistic minorities since before the time of the Seljuk and Ottoman Empires. Thus, many languages
—Turkish, Arabic, Persian, Kurdish, Greek, Bulgarian, Romanian, Albanian, and Armenian–have
been spoken in the region. Following the establishment of the modern Republic of Turkey, Turkish
was made the official language in the 1924 Constitution and has been the dominant language since
then. Currently, about 80% of Turkey’s inhabitants speak Turkish, about 15% Kurdish and the
remaining Arabic or other languages (KONDA, 2006). A report by Morgül (2008) indicated that there
were 36 languages spoken as a first language in Turkey. Thus, today there is a growing linguistic
diversity and Turkish not only is an L1 but also is a second language (L2) in the homeland. Since
the last decade, bilingualism and its implications for academic and social success and language
disorders in both monolingual and bi- or multilingual children is receiving a remarkable interest
for the following reasons (Topbaş, 2011; 2012):
 Recently, international immigration and mobility have been changing the structure
of the society. Increasing immigration from Middle-Eastern, Eastern-European,
Russian, or other countries led to Turkey welcoming new languages and cultures.
 The medium of instruction in education is Turkish given its status as the official
language of Turkey. So, children whose mother tongue is not Turkish face the
difficulty of receiving necessary formal support in their L1. Only the Greek of Turkish
citizenship, Armenian, and the Jewish students have the opportunity to be educated
in their own languages.
 There are vast regional disparities, where the lowest enrolment rates in pre-primary
and primary education are observed in main multicultural South-Eastern and
Eastern Anatolian provinces.
 Compared to studies in Turkish as L1, there is little documentation of the children’s
L1 or age of acquisition norms or the age when Turkish as L2 is typically introduced.
It is apparent that Turkey is becoming increasingly diverse, thus multilingualism is
prominent. The main concern for the SLPs may be that they are often considered the expert
in how to appropriately address therapeutic or educational needs for individuals with diverse
linguistic and cultural backgrounds. However, there are few SLPs in Turkey and there is not
enough formal information or guidance on these languages related to multicultural issues.
Therefore, it may be challenging for Turkish SLPs aspiring to provide effective and equitable
services to those multilingual children with SLDs in the homeland (Topbaş, 2011; 2012).
Information about the speech and language development of multilingual children is essential
to interpret the performance of children with speech language disorders. It is important to assess
both languages in order to understand whether difficulties stem from a lack of exposure to either
language or are specific to impairment and if any difficulty arise, what intervention or remedial
approaches are needed (International Expert Panel on Multilingual Children’s Speech, 2012; McLeod,
2012b; McLeod, & Goldstein, 2012).
Thus far, the individual differences and the language problems observed in some
bilinguals in and beyond the country drive the need for collaborative research and policies in
solving the issues of assessment of language (specific), speech impairments and the difficulties in
speech-language therapy services in the multicultural settings for Turkish as L1, as well as L2.
Consequently, a national project had been conducted in collaboration with EU countries under
the COST Action IS0804 (Bi-SLi, n.d.), to develop tests for profiling the difficulties that children
with language impairments have in their first (Turkish) and second language spoken in countries

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 where they have migrated. Many tests on sentence repetition, non-word repetition, narrative-
based, and lexical development have been developed in several languages (Bi-SLi, n.d.).

Turkish Language
Turkish is in the Southwest group of Turkic languages belonging to the Altaic branch
of the Ural-Altai linguistic family. Turkish is an agglutinative language with rich morphology.
That is, it is a predominantly inflected language and relies heavily on suffixes. Inflections are
attached to the root morphemes, each of which has only one meaning or grammatical function.
In strings of morphemes, each element retains its phonological and semantic identity as well
as its relative position in it. The order of morphemes is fixed in that derivational morphemes
precede the inflectional ones in stem words (Göksel & Kerslake, 2005). Inflectional morphemes
constitute the grammatical functions. The following example (1) shows that when the inflectional
morphemes are attached to nominals, they mark plurality-number, possession, and case in that
order; and when are attached to verbs, they mark voice, negation, tense-aspect-modality, and
person-number.
(1) (Ben) El - ler - im -iyıka -ma - dı -m.
( I ) Hand -PL -POSS1S -ACC wash- NEG –PAST -1S
I didn’t wash my hands.
Ellerimi yıkamadım.
Although flexible for pragmatic purposes, the neutral word order is subject-object-verb (SOV),
with accompanying properties of suffixed inflections, postpositions, and preposed demonstratives,
numerals, possessives, adjectives, and relative clauses. Being a null-subject language, subject nouns
are omitted but omission of object nouns depends on the context. As can be seen in example (1)
“Ben (I)” is considered as a null-subject, there is no obligation to use it since it is indicated by the
first person singular morpheme “–m” inflection added to the verb. Thus, the subject is indicated by
agreement marking on the verb. Gender is not expressed. Turkish does not have a definite article.
Although the accusative case marking has a definitizing function in some structures, in many
instances, definiteness is marked by word order. For example, the accusative case (-I ) is used if a
definite noun is the object of the verb as in (2a), but not used if the object is indefinite as in (2b; a
summary of Turkish grammar can be found in Yavaş, 2010).
(2) (a) Kedi et-i ye-di
cat meat-ACC eat- PAST3SG
(b) Kedi et ye- di
cat meat eat- PAST3SG
Turkish uses the Latin alphabet which contains 29 letters in the orthography with
one-to-one correspondence between sounds and letters. There are 21 consonants (p, b, t, d,
k, g, f, v, s, z, ʃ, ʒ, h, m, n, ɾ, l, j, ʧ, ʤ) and 8 short vowels (a, e, ı, i, o, ö, u, ü). The canonical
syllable type is CV, allowing syllable structures as (C)V(C)(C), in that the vowel nucleus is the
only obligatory element. There are no onset clusters; only certain cluster codas (C1= sonorant +
C2= obstruent; C1= fricative + C2= stop), consisting of no more than two consonants are permitted.
The maximum Onset First Principle (Clements & Keyser, 1983) is a major assignment for clusters
and sequences of two consonants. All vowels in native words are subject to vowel harmony and
morphophonological alternations may occur due to vowel and consonant harmony during suffixation.
Being a syllable-timed language, each morpheme is syllabic and stress is usually on the last syllable
of the word (a summary of Turkish sounds can be found in Kopkallı-Yavuz, 2010).

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 Language Acquisition Tips
Speech-language pathologists (SLPs) can find quite a good amount of research on the
language acquisition of Turkish in children (for comprehensive summary chapters see Topbaş &
Yavaş, 2010). Children tend to master the phonology of their language rapidly (Topbaş, 2006a).
The order of acquisition of consonants is stops>nasals>affricates>glide>liquids>fricatives>flaps
(Topbaş, 2006b). Late acquired sounds are /z/ (4–5 years) and /r/ (5–6 years). Some phonological
processes such as fronting and stopping, flap/liquid gliding/deviation and word final cluster
reduction may not stabilize until around 4 years (Ege, 2010; Topbaş, 1997; 2007; 2011; for a
summary McLeod, 2012a). Vowels and vowel harmony rules are acquired very early although
exceptions may take a long time to master (Altan 2009; Nakipoğlu-Demiralp & Ketrez, 2007).
Turkish children show early sensitivity to the basic word order, inflectional and morphosyntactic
system (2–3 years). However, some grammatical structures such as embedded relative clauses and
noun clauses are acquired at much later ages. The influence of the ambient language is evident in
the realization of error patterns (Aksu-Koç, 2010; Ketrez & Aksu-Koç, 2009; Küntay, 2002; Topbaş
& Maviş, in press).

SLP Profession in Turkey

Turkey has recently developed a model for training of professionals in the area of
communication disorders. The department of Speech and Language Therapy at Anadolu University
laid a foundation in 1999 with the establishment of the Education, Research and Training Centre
for Speech and Language Pathology (DILKOM) for the education of speech and language therapists,
their practicum, and graduate research. This center has led to the establishment and autonomy
of speech and language therapy as a profession in the country. In the 2000–2001 academic years,
following the American Speech-Language-Hearing Association (ASHA) principles, the Graduate
Department of Speech and Language Therapy established Masters and PhD programs (Topbaş,
2006c; 2010a). In 2012, an undergraduate program was founded in the Faculty of Health Sciences
followed by a separate department of audiology. The second undergraduate program in the country
was initiated in 2013 at Hacettepe University, where there are two programs as well: speech and
language therapy and audiology (AUD). The students of both universities also have the advantage
of doing practica at university hospitals. Since 2011, the professional laws are governed by the
Ministry of Health, where the diplomas have to be approved.
Currently, staffing and permanent employment of SLPs is one of the main problems in
both the health and education sectors. The past studies reported in Topbaş (2006c; 2010a), revealed
tremendous inefficiency in services for individuals with SLDs and poor quality of services due to
the shortage of SLPs. However, by 2013, 129 SLPs (including CCC-SLP diploma from the United
Kingdom and United States) and about 180 AUDs had graduated from the above programs and about
90 candidates from both disciplines are expected to treat people with all types of communication
impairments. There are also a few Bulgarian–Turkish pedagogic speech therapists serving. Thus,
currently, the vast majority of care providers are non-SLPs with little training in communication
disorders.
Depending on the needs of individuals with speech and language disorders (SLD), SLP
services must be prescribed by a team of medical doctors in the authorized main hospitals. Children
under the age of 18 are then referred to Psychological Counseling and Guidance Centers affiliated to
Ministry of National Education of Turkey (MoNE) within each city where intervention decisions are
administered and referred to special education schools or private practice/rehabilitation centers
for treatment. Other health professionals or schoolteachers often refer clients, or the families seek
direct services themselves. If medical treatment is also needed, or if the individual is an adult,
usually the services are given within the hospital and/or private practice centers.
At the moment, systematic SLP services cannot be properly delivered in Turkey. Due to
the shortage of staff, each SLP or AUD generally carries a heavy caseload. One important problem

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 noted is that a physician may not refer a non-speaking child with a developmental communication
disorder if the etiology is unknown, until the child is 4–5 years of age or older. Thus, language
impairments with unknown etiologies such as, language impairments (primary/specific language
impairment) may often go undetected. Medical personnel refer cases of laryngectomy, aphasia and
voice disorders to an accessible SLP if there is one working at the hospitals.
Notwithstanding, as mentioned above, at the research center, DI˙LKOM in Anadolu
University comprehensive assessments and evaluation procedures are routinely conducted. Many
research attempts have been made in language acquisition and communication disorders as well
as to develop diagnostic and treatment protocols for this specialty area within the last few years
(Özdemir, St. Louis, & Topbaş, 2011a; 2011b; Topbaş, 2010b; Topbaş & Ünal, 2010;). Table 1
shows a list of examples.

Table 1. Recently Developed Speech and Language Assessment Tools in Turkish.

Tools Authors Norms

Ankara Articulation Test (Ankara Artikülasyon Testi-AAT) Ege, Acarlar, & Turan (2005) +
Turkish Articulation–Phonology Test (Kit) (Türkçe Topbaş (2004) +
Sesletim-Sesbilgisi Testi-SST)
Test of Early Language Development (TELD-3, Hresko, Reid, Topbaş & Güven (in press) +
ve Hammill, 1999) Turkish version (Türkçe Erken Dil Gelis¸im
Testi)
Test of Language Development (TOLD-4,Primary; Hammill & Güven & Topbaş (in preparation) +
Newcomer, 2008): Turkish version (Türkçe Okulçağı Dil
Gelişim Testi)
MacArthur Communicative Inventory (CDI- Fenson) Turkish Aksu-Koç et al. (2013) +
(TI˙GE-Türkçe I˙letis¸im Gelis¸im Envanteri)
Aphasia Language Assessment Test (Afazide Dil Deg˘ Maviş & Toğram (2009) +
erlendirme Testi-ADD)
Gülhane Aphasia Test-2 (Gülhane Afazi Testi-GAT-2) Tanrıdağ, Mavis¸, Topbaş (2010) +
Systematic Analysis of Language Transcripts – (SALT), Acarlar, Miller, & Johnston, N/A
Turkish (Version9) [Computer Software] (2006)
TI˙FALDI˙ – Turkish Expressive and Receptive Language Test Güven & Berument (2010) +
of Vocabulary
Maternal Behavior Rating Scale (MBRS- Mahoney, 2008) and Diken, Topbaş & Diken (2011) N/A
Child Behavior Rating Scale (CBRS-Mahoney & Wheeden, 1999)
GOPDÖ-2-TV-Gilliam Autism Rating Scale-2-Turkish Version Diken, Ardıç, & Diken (2011) +
LARSP – Language Assessment, Remediation and Screening Topbaş, Cangökçe-Yaşar, & Ball N/A
Procedure (Crystal, 1982) - Turkish (2012)
Turkish Nonword Repetition Test Topbaş, Kaçar-Kütükçü & N/A
Kopkallı-Yavuz (2014)
LiTmus-Sentence Repetition Test: Turkish Topbaş, Aydın, Kazanoğlu, & N/A
Tadıhan-Özkan (submitted)

Treatment sessions are conducted either individually or in small groups depending on

the nature of the problem and the individual. For speech disorders, several traditional and
current approaches described in the literature are used in treatment. One of the priorities of
the new legislation is to develop an individualized education plan (IEP) for every client. In order

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 to achieve this goal, the first formal national individualized education curriculum has been
developed very recently by a collaborative team of SLPs, audiologists, teachers of special education,
and staff of the ministry (MoNE, 2009). The curriculum covers articulation and phonological
disorders, fluency disorders, voice disorders, and language delay, and gives general guidelines
and procedures for implementing assessment and therapy through daily or weekly logs. The
curriculum program is for use by SLP and AUD professionals employed in public and/or private
practice special education or rehabilitation centers. It is of concern that this curriculum however
does not include any special intervention programs for children with SLI. Further, much more
attention needs to be directed towards consistency in implementation of intervention methods
or approaches.

Linguistic and Cultural Considerations for SLPs

in Multilingual Contexts
In Turkey, since the last decade, a change is being witnessed towards more positive attitudes
to communication disorders with public awareness campaigns on the rights of individuals. Recent
research studies conducted on public awareness of acquired neurological language disorders
indicated that aphasia, multiple sclerosis, and traumatic brain injuries are the least known disorders
whereas epilepsy, dementia, and Alzheimer’s disease receive growing interest (Maviş, 2007; Maviş &
Akyıldız, 2013).
But there is still a greater focus on the differences and weaknesses of people. Thus,
parents of children with speech-language-hearing or communicative disorders may face negative
reactions because of the societal attitudes towards labeling. In the author’s experience, parents
report constantly feeling ashamed and spend considerable time denying the existence of a condition.
School performance and success is an important criterion, specifically for male children; this has an
impact on disorders such as stuttering/cluttering as well as communicative competency. This seems
an important issue because families especially from rural areas tend to believe in the supernatural
and continue taking their children to non-medical people or hodjas in order to improve speech/
language difficulties.
It is still common in Turkey for families to take care of their elderly parents; however, as
SLDs are accepted as ailments of normal aging, families seldom seek therapy unless medical
doctors refer them. Although there is a changing trend among medical personnel, they are still
not aware of the detrimental effects or consequences of SLDs and the role of the SLP in services.
Whatever the case may be, families or parents cannot maintain long-lasting therapy due to many
problems, the most important one being financial (Topbaş, 2006c; 2010a). This was supported by
the Disability Survey 2002, which showed that the lowest number of individuals receiving
treatment in both health and special education systems were those in the SLD category with
32.92% (Tufan & Arun, 2006).
In accordance with the information given above, considering the following hints will be
beneficial for the United States/European SLPs who will be working with Turkish patients both
in and outside Turkey (ASHA, 2004; Topbaş, 2006c; 2010a):
The family structure of Turkish people is autocratic culturally; the father/the older male
is dominant as the decision-maker for family matters (although in big modern cities there is a
changing attitude towards more democratic parenting styles). The mother is the primary caregiver,
but sometimes keeps her silence in front of her husband. Therefore, taking a case history may
be difficult in front of husbands. Many times, father’s resist to therapies thus the SLP should be
decisive to persuade the father of a need for therapy.
 Even though male medical doctors or specialists receive greater respect than their
female colleagues, being a doctor or a therapist is highly regarded as a profession.
Accordingly, both male and female SLPs are treated as worthy professionals.

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  Doctors usually use direct language in their recommendations for medical care; thus
SLPs should use high levels of directness in their requests to Turkish migrant families.
 Religious factors should also be taken into consideration. Since Turks are Muslims
they fast during Ramadan. Clinicians should consider Muslim holidays and
celebrations when scheduling treatment sessions.
 An impairment or disorder may be annotated to God’s will which might affect a
family’s motivation to address change, and may mean resistance to therapy.
 If the client, especially male, holds strong religious beliefs, assessment and therapy
activities such as oral-motor examination, thermal stimulation, handshaking,
or physical contact should carefully be monitored, be explained pre-therapy, or
should be done with permission. In such circumstances, an SLP of the same sex
or a translator might be helpful.
 Diagnostic criteria in the L2 milestones may misdiagnose and/or mislabel the child,
so clinicians should be aware of Turkish (as L1) developmental milestones.
 With Turkish individuals who are already bilingual, speak English in an intermediate/
advanced level, and children who are learning Turkish and English bilingually,
standardized, and non-standardized diagnostic assessments may be conducted in
both languages by a Turkish SLP or a team that includes a non-Turkish speaking
SLP and a Turkish language interpreter. Treatment sessions also should follow a
similar approach where a team of SLPs and interpreters work in collaboration.
In conclusion, speech-language pathology profession is blooming in Turkey. As with
their counterparts in the world, SLPs in Turkey view direct service provision as central to their
professional identity. By the recent establishment of undergraduate programs, more SLPs
will be trained, which will lead their role for direct care provision, in-service training of other
professionals, and doing effective research in communication disorders. Encompassing the joint
efforts of the few SLPs in the country with those in the United States, EU, or the world in sharing
ideas, research in speech therapy activities may further develop the field and the recognition of
the profession as direct and highly specialized clinical services.

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