Lost in translation

07 September 2017

In a multilingual society and with interpreters in short supply, should children act as their parents’ language brokers with health professionals – even if they have embarrassing or taboo conditions? George Guiton, James Dunne and Fiona Finlay explore the issues.

In a multilingual society and with interpreters in short supply, should children act as their parents’ language brokers with health professionals – even if they have embarrassing or taboo conditions?

When families move to a new country, the children often become fluent before their parents in the new language, which acts as a gateway to understanding services and cultural norms. Children and young people may be expected to interpret for their family members, and although this may be acceptable during day-to-day activities, it is not ideal in all situations, such as communicating with healthcare professionals during appointments or hospital admissions.

The doctor-patient relationship is based on good communication. The GMC (2013) recommends that doctors should:

  • Listen to patients, take account of their views and respond honestly to their questions
  • Give patients the information they want or need to know in a way they can understand
  • Make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs
  • Be considerate to those close to the patient and be sensitive and responsive in giving them information and support.

It is recognised that a language barrier may affect health outcomes through miscommunication, inadequate understanding of diagnosis or prognosis, misinterpretation of advice or instructions, limited joint decision-making, and lack of informed consent or ethical compromise (Silva, 2016). These factors may hinder patients in being active participants in decision-making about their treatment.

Interpreter dynamics

Studies have highlighted the benefit of using professional interpreters, rather than family members, members of staff or telephone interpreting services. In a systematic review, Karliner et al (2007) found that in all areas studied – communication, clinical outcomes, utilisation satisfaction – using professional interpreters improved care compared with using ad hoc ones. Length of inpatient admissions were reduced, with increased delivery of preventative health measures, coupled with greater treatment compliance (Jacobs et al, 2001).

However, using an unknown professional interpreter can affect consultations when dynamics are altered, a traditional two-person dynamic becoming three-person, which adds complexity to the consultation (Fatahi et al, 2008). Without ‘small talk’ it is harder to build a good doctor-patient rapport and consultations may feel ‘colder’ (Aranguri et al, 2006).

While ethical guidelines say interpretations should be exact, Clifford (2005) believes that interpreters can do more than translate directly, acknowledging situations that require intercultural inquiry to ensure complete understanding, thereby facilitating truly informed consent. Interpreters should speak the same language and dialect as the patient, and have knowledge of the medical system and its terminology. They should not speak on behalf of the patient in response to questions posed directly to the individual, but should directly interpret their response (Humphreys, 1999). They should be non-judgmental, ask questions sensitively, not impose their own political or private views and preferably be the same sex, particularly when dealing with sensitive issues (Ngo-Metzger et al, 2003; Das, 2009). Although interpreters should respect confidentiality and sign a confidentiality agreement, for some families, in some situations, it is important that the interpreter is from outside their network or community (Brandon, 1999).

Professional interpreters are considered expensive and generally require advance booking. Although healthcare providers strive to provide professional interpreters this is not always possible, as they are rarely available at short notice or in emergency situations. Family members, however, are often readily available at no cost, and are usually willing and eager to interpret.

In a study of 3435 resident physicians from 149 hospitals, Lee et al (2006) found that 84% had asked family members or friends to interpret – and 22% used children. However, family members may lack the necessary vocabulary to translate complex medical issues accurately, and the patient may not want to share information with their relatives (Ngo-Metzger et al, 2003). There may be uncertainty about impartiality, and relatives interpreting may withhold information from patients about, for example, the side-effects or risks of treatment, believing that this will increase compliance (Das, 2009).

Meyer (2010) argues that in some scenarios family interpreters may be beneficial, providing additional information and shortening the consultation by interacting directly with the medical staff. Family members can provide continuity of care, being a source of knowledge on returning home (Russell et al, 2015). From a clinician’s perspective, Gray et al (2011) found that untrained interpreters – generally family members – work well 88% of the time for ‘on-the-day’ consultations, but only 36% of the time for booked consultations.

Communication breakdown

Interpreter errors of clinical consequence made in one trial of pediatric encounters included the following:

  • Omitting questions about drug allergies
  • Omitting instructions on dose, frequency and duration of antibiotics and rehydration fluids
  • Adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash
  • Instructing a mother not to answer personal questions
  • Omitting that a child was already swabbed for a stool culture
  • Instructing a mother to put amoxicillin in both ears for treatment of otitis media.

(Source: Flores et al, 2003)

A big responsibility

Children are often asked to interpret. This may cause stress, anxiety, frustration and embarrassment for both the child and the parent. Children may lack fluency in either language, and the conceptual skills and the emotional maturity to act as a linguistic and cultural mediator. They may be asked to maintain confidentiality and keeping secrets may place an unfair burden of responsibility on them. They may worry about getting important information wrong, which may have serious consequences. If there are poor health outcomes children may blame themselves. Oral interpretation requires good listening skills and immediate recall with the ability to convert meaning on the spot from one language to another (Baker et al, 1991). Children are unlikely to be able to interpret accurately if they have limited understanding of medical terminologies and the nuances of health issues, and they may not understand concepts of diagnosis, treatment and prognosis, making interpreting difficult.

Even when professional interpreters are used there is difficulty with interpretation. Flores et al (2003) reviewed encounters with Spanish interpreters, categorising errors and determining their consequence. They found a mean of 31 errors per encounter, ad hoc interpreters being more likely to commit errors with potential clinical consequences than a professional interpreter (77% versus 53%). Omissions were the most frequent error (52%), followed by false fluency (16%), substitution (13%), editorialisation (10%) and addition (8%) (see box).

In another small study, Prince et al (1995) analysed interactions between patients and eight physicians who had undertaken a 45-hour medical Spanish course during their first residency month and found minor errors in more than half and major errors in 14%.

Children should not be expected to interpret information that is potentially sensitive, embarrassing or inappropriate: for example, menstruation or their parent’s sexual history. They should not have the responsibility of breaking bad news to their parents, for example, the diagnosis of cancer (Levine, 2006).

Children may provide inaccurate or limited information to their parents and parents in turn may want to protect their children. As a result parents may not share the necessary information required to reach a diagnosis, and ultimately receive the correct investigations and treatment, or they may not share information that they wish to keep confidential from the child: for example, domestic abuse, financial difficulties or problems at work.

Children should not be asked to interpret where there are safeguarding concerns. In such circumstances social workers should communicate with the family using a specifically trained professional interpreter suited to the task at hand, to ensure that there is no misinterpretation, manipulation, obstruction or collusion (Chand, 2005). In some languages it is difficult to interpret the words and phrases around sexual abuse, with mistranslation occurring for anatomical words because of cultural differences in the ways that body parts are named (Chand, 2005; Cohen, 1999), and asking children to try to do so would be totally inappropriate.

The child may resent acting as an interpreter, especially if it means missing outings with friends or taking time off school to attend appointments. It may also shift the position of power and responsibility so that the moral order and the family dynamic is reversed, with the parents perceiving a loss of authority over the child, who in turn might feel they have power over the parent.

George Guiton, James Dunne and Fiona Finlay explore the issues around children acting as parents' translators

Family conflict

This role reversal, with the child acting as a linguistic and cultural mediator, is disempowering for the parents and may result in conflict within the family, damaging relationships between parents and children (Narchal, 2016; Hua, 2012).

Children may come to know things ‘before their time’ and not only may their innocence be dissipated, but their precocious knowledge may affect their development into stable, adjusted adults (Cohen et al, 1999). When children view interpreting as a burden, this may act as a stressor, with psychological consequences, including increased risk-taking behaviours and drug and alcohol misuse, whereas those who feel positive about their role may not have any adverse behavioural or mental health outcomes (Narchal, 2016; Kam, 2014).

It is important that healthcare professionals recognise the problems of using a child as an interpreter. Russell et al (2015) looked at the experience of staff who used children as interpreters during pediatric consultations. Ten professionals were interviewed about their knowledge on policies for communicating with patients with limited proficiency in English. The authors found limited awareness of implications of using children as interpreters and stressed the need for further education about the potential risks children face when interpreting medical information, and of the potential negative impact the process may have on medical outcome for patients.

There are some instances when it could be argued that it is appropriate to have a child acting as an interpreter, and some parents prefer to use their children as interpreters as they are concerned about confidentiality if an interpreter from their local community is involved. Cohen et al (1999) explored GPs’ views on the appropriateness of children interpreting during primary care consultations, where there is often a limited availability of professional interpreters. They found that the acceptability of children as informal interpreters depended on whether the medical consultation was likely to be straightforward, complex or sensitive. In some instances they were happy to have teenage daughters acting as interpreters but not sons: for example, when discussing gynaecological problems, or other taboo parts or functions of the body.

GPs experienced a reluctance to have children interpreting but felt there was a professional responsibility and pragmatic need to proceed with the consultation once the patient had arrived. They expressed an ideological opposition to the appropriateness of this task for children generally, feeling that this added responsibility can deny children their right to a ‘proper’ childhood, characterised as a time of innocence and freedom from worry.

Any benefit?

There may be some benefits for children who act as interpreters. Studies show that children who interpret have enhanced emotional, social, interpersonal and cognitive skills, performing better on standardised tests for maths and reading than their peers (Narchal, 2016).

A study within schools has shown that many young people presented a very positive picture of interpreting within a school environment, taking pride in the role, talking to new people, increasing their confidence and noting that it earned them respect and admiration from others.

Teachers reported that in some cases it enhanced pupils’ confidence, increased their sense of belonging and offered a form of empowerment, as long as the teaching staff perceived bilingualism as an asset, acknowledged the responsibility that came with it and did not ask them to interpret in sensitive situations. Young people from bilingual backgrounds may act as ambassadors, showing new pupils and parents around the school, helping at parents’ evenings, and in urgent situations communicating with a parent on the telephone, for example, if another child is ill (Cline et al, 2014).

Lee et al (2006) found that 77% of residents had asked hospital employees to interpret. Although they have knowledge of healthcare, and some patients may feel more comfortable having a staff member interpreting, studies have shown that their interpretations are limited in accuracy. Moreno et al (2007) found that one in five dual-role staff interpreters had insufficient bilingual skills to act as an interpreter, and Elderkin-Thompson et al (2001) found there were serious miscommunication problems in about half of the encounters between Spanish speaking patients and nurses with no formal interpreting training. Nurses provided information that was congruent with clinical expectations but not with patients’ comments, and some patients explained symptoms using a cultural metaphor, resulting in a misunderstanding. Relying on untrained, ad hoc interpreters may ultimately compromise clinical care (Levine, 2006).

Key principles of working with interpreters

  • Brief the interpreter before the consultation and debrief after
  • Position yourself so that you face the patient rather than the interpreter
  • Always maintain eye contact with the patient and direct the questions to him or her
  • Speak simply and pause often
  • Respond to non-verbal cues
  • Check the patient’s understanding
  • Where possible use the same interpreter for future interviews.

(Source: Das, 2009)

Linguist skills gap

If professional interpreters are not available, instead of asking staff, family members or children to interpret, telephone interpreting services may be used. These cost little and their use receives mixed ratings (Gray, 2011). Lee et al (2002) found that patients using telephone interpretation are as satisfied with their care as those seeing language-concordant staff, while those using ad hoc interpreters or family members are less satisfied.

Clinicians report that while telephonic interpretation is satisfactory for information exchange, it is less good for establishing rapport and for facilitating understanding of cultural and social background (Price et al, 2012), and it is of course not suitable for patients with a hearing impairment.

It is important that healthcare staff receive adequate training in communicating with patients with limited proficiency in English and know how to obtain an interpreter. Lee et al (2006) found that 35% of resident respondents cited a lack of instruction in providing care involving an interpreter, 55% had little or no instruction on assessing patient literacy, 54% reported a lack of access to interpreters and 58% cited a lack of time when delivering cross-cultural care.


Although it is recommended that children do not act as interpreters, it can be argued that with limited availability of professional interpreters, children may be acceptable if the consultation is likely to be straightforward. Children should not be used when consultations are complex, involving discussions about difficult or sensitive issues, including prognosis, symptom control or end-of-life planning.

In emergency situations it may not be feasible to wait for an interpreter without risking serious harm to the patient, and in such circumstances children may be asked to interpret, the priority being to provide treatment to prevent harm. However, in these instances children would need support to mitigate the impact of interpretation.

The realities of using child interpreters

NHS policy says that interpretation and translation should be provided free at the point of delivery, be of a high quality, accessible and responsive to a patient’s linguistic and cultural identity.

But the cost is considerable. A report by 2020Health found that the NHS spent £23m a year on translation and interpreter services in 2012, an increase of 17% since 2007.

NHS England says that the use of an inadequately trained interpreter poses risks for both the patient and healthcare provider and may be more risky than having no interpreter at all.

To help manage costs, NHS Shared Business Services (NHS SBS) was established in 2004 to deliver £1bn savings to the NHS by 2020.

Face-to-face, phone, and BSL interpretation and document translation are available via the NHS SBS. NHS providers can select these services from suppliers on the NHS SBS’s list.

But when one supplier went into liquidation this year, Unite called on the government to investigate how interpretation contracts are awarded. It said a ‘race to the bottom’ in public sector outsourcing was adversely affecting people who rely on interpreting services.

Unite said that cost-cutting across the sector was driving away interpreters from the profession as they could not afford to live on the wages. Unite, which embraces the National Union of British Sign Language Interpreters (NUBSLI), said that skilled interpreters were being paid as little as £12 an hour, while the NUBSLI said freelance rates for fully qualified interpreters in London were £260-a-day.


George Guiton is a student at the University of Sheffield; James Dunne is designated nurse safeguarding children at NHS Wiltshire Clinical Commissioning Group; and Dr Fiona Finlay is a paediatrician at Virgin Care in Bath.



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