Perspectives of the ASHA Special Interest Groups

SIG 14, Vol. 3(Part 1), 2018, Copyright © 2018 American Speech-Language-Hearing Association

Evidence-Based Clinical Decision Making for Bilingual

Children With Autism Spectrum Disorders:
A Guide for Clinicians
Vanesa Smith
Connie Summers
Vannesa Mueller
University of Texas at El Paso

Alejandra Carillo
Gabriela Villaneda
Ysleta Independent School District
El Paso, TX
Disclosures
Financial: Vanesa Smith has no relevant financial interests to disclose. Connie Summers has no
relevant financial interests to disclose. Vannesa Mueller has no relevant financial interests to
disclose. Alejandra Carillo has no relevant financial interests to disclose. Gabriela Villaneda has
no relevant financial interests to disclose.
Nonfinancial: Vanesa Smith has no relevant nonfinancial interests to disclose. Connie Summers
has no relevant nonfinancial interests to disclose. Vannesa Mueller has no relevant nonfinancial
interests to disclose. Alejandra Carillo has no relevant nonfinancial interests to disclose. Gabriela
Villaneda has no relevant nonfinancial interests to disclose.

Speech-language pathologists (SLPs) are treating an increasing number of bilingual clients,

including those diagnosed with autism spectrum disorders (ASDs). There is not a clear
consensus among professionals regarding which language should be used in intervention
when treating bilingual children with ASD. For this reason, it is imperative that SLPs ensure
that they are making evidence-based decisions. This article will review the current research
that examines bilingualism in children with ASD along with research focused on the language
of intervention in bilingual children with ASD. We present a clinical scenario with common
concerns presented to SLPs in their work settings and outline how current evidence can
be used to address these concerns. We also provide evidence-based recommendations for
parents and professionals.

Individuals who speak a language other than English now comprise 21% of the population
in the United States with higher proportions in some states (i.e., 35% in Texas; U.S. Census
Bureau, 2013). With the current prevalence of autism spectrum disorders (ASDs) being one in
68 children (Center for Disease Control and Prevention, 2017), the growing bilingual population
means that more bilingual children will be diagnosed with ASD (Mueller, Singer, & Grace, 2004)
and need services. A clear consensus has not been established among professionals, including
speech-language pathologists (SLPs) regarding the selection of appropriate language(s) to use in
intervention when working with children with ASD (Kay-Raining Bird, Lamond, & Holden, 2012).
SLPs are challenged with making these decisions on a regular basis, and it is imperative that
current evidence be used to ensure the best practices. In this article, we present a clinical scenario
increasingly common to SLPs who work with bilingual children diagnosed with ASD. We identify
the main concerns in the clinical scenario regarding language of intervention, review the current

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 research pertaining to these issues that can and should be used in clinical decision making, and
include evidence-based recommendations for practicing clinicians.
Clinical Scenario
Jessica is a bilingual SLP who just received a new transfer student on her caseload. David
is a 5-year-old kindergarten student diagnosed with ASD. His family speaks primarily Spanish
in the home, and he attended an Early Childhood school program starting at the age of 3 years
that was taught in English. He currently speaks in two to three word utterances (e.g., dame juice,
more queso) and uses both English and Spanish words. He can follow simple commands (one step
in both languages). Jessica has recently completed his reevaluation and shared a copy of the draft
of her report with the special education teacher and the vice principal so that they can review it prior
to the individualized education program meeting. In her recommendations, Jessica notes that she
will be providing services in both English and Spanish. The special education teacher and the vice
principal stop by her office to question why she is making this recommendation and note that they
differ in opinion. They request that Jessica instead provide therapy in English only as that is the
language of instruction in the classroom. The special education teacher adds that she has already
spoken to David’s parents and recommended that they also speak only English to him at home to
facilitate his progress in the classroom. Jessica recognizes that this difference of opinion has created
an ethical dilemma for her as she needs to disagree with her team and provide the appropriate
justification for her recommendation.
How Does Jessica Respond and What Does the Evidence Say About the Language of Intervention?
Jessica listens to her team and understands their concerns but wants to ensure that she
is making ethical decisions that align with the current evidence. She has recently completed a
literature review to guide her decision-making process with another student and feels confident
that the current evidence supports the use of the home language in therapy. Jessica understands
that taking a bilingual approach will help support David’s academic success in school without
negative impact to his communication and social interactions within his family. Jessica wants to
help her team understand why she is making the recommendation of providing therapy in both
languages, by reviewing with them what the current research has shown. The team expresses the
following three main concerns:
1. David is already delayed in his communication skills, and treating him in two languages
will put him further behind.
2. David receives instruction in English in the classroom, so therapy in Spanish would
not support his progress in the classroom.
3. David’s family has already been encouraged to speak only English at home to help
him perform better in the classroom.

Team Concern 1: David Is Already Delayed in His Communication Skills and Treating Him in Two
Languages Will Put Him Further Behind
There is a misconception that bilingual children with disabilities have additional delays
when compared with their monolingual peers. Given that the literature on bilingual children
with ASD is limited, Jessica also examined current evidence for children with different diagnoses
that affect language. There is no evidence to support the idea that being bilingual will result in
additional language delays for children with primary language impairments (Gutiérrez-Clellen,
Simon-Cereijido, & Wagner, 2008; Korkman et al., 2012; Paradis, Crago, Genesee, & Rice, 2003),
Down syndrome (Feltmate & Raining-Bird, 2008; Kay-Raining Bird, Cleave, Trudeau, Thordardottir,
& Sutton, 2005), or ASD (Drysdale, van der Meer, & Kagohara, 2015; Hambly & Fombonne, 2012;
Petersen, Marinova-Todd, & Mirenda, 2012; Valicenti-McDermott et al., 2012) when compared with
their monolingual peers.
When reviewing the literature focused on bilingualism in children diagnosed with ASD,
Jessica discovered that bilingual language environments do not hinder their language development
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 (Drysdale et al., 2015; Hambly & Fombonne, 2012; Park, 2014; Petersen et al., 2012; Valicenti-
McDermott et al., 2012). Hambly and Fombonne (2012) divided their bilingual participants with
ASD into two groups, a simultaneous bilingual group and a sequential bilingual group, and did not
find differences between these two bilingual groups and their monolingual peers with ASD. Similar
results have been found with participants who speak other languages, such as with English–
Chinese bilingual preschool children (Petersen et al., 2012) and English–Spanish young children
(Valicenti-McDermott et al., 2012). Evidence shows that bilingual children with disabilities have
the capacity to function successfully as bilinguals. Just as important is the finding that bilingualism
does not impede language learning in children with language difficulties, including children with
primary language impairment, Down syndrome, and ASD. Jessica explains to her team that, on
the basis of this level of evidence, she is confident that using David’s home language in therapy will
not put him further behind.
Team Concern 2: David Receives Instruction in English in the Classroom, So Therapy in Spanish
Would Not Support His Progress in the Classroom
It is easy for Jessica to understand this concern, and despite a lack of evidence to support
monolingual intervention, intervention is typically delivered in the community’s majority language
as her team has requested (Mueller et al., 2004; Paneque & Rodriguez, 2009). Jessica has read that
professionals often favor one language over the other, instead of considering a bilingual approach.
Such intervention decisions utilize two underlying erroneous assumptions about children with
disabilities (see Guiberson, 2013, for a detailed discussion), including children with ASD.
The first assumption is that children with disabilities will be unable to successfully acquire
more than one language because exposure to two languages will result in a cognitive overload
(Ohashi et al., 2012). Cummins (1984) described a similar assumption as a separate underlying
proficiency, which would indicate that bilinguals experience little transfer of knowledge or skills
from one language to another. In contrast, he described a common underlying proficiency,
suggesting that having a foundation in one language would help a child learn a second language.
Cummins’ interdependence hypothesis (Cummins, 1979) has been suggested to support the
assumption that a child’s native language and second language are interdependent upon each
other, thus impacting each other positively or negatively (common underlying proficiency not
separate underlying proficiency). If a child is experiencing language delays in their first language,
then it would be harder to acquire a second language. However, Cummins argued clearly that
any instruction in English will only be enhanced by the use of a child’s first language (Cummins,
2009). Indeed, a relationship between two languages does not mean that one language must be
mastered before introducing a second language.
A second underlying assumption in limiting intervention to one language is that a child
in a bilingual environment will not have sufficient opportunities to be exposed to each language,
resulting in two underdeveloped language systems (Goldstein, 2012). This assumption leads
to the idea that restricting input to a single language will provide greater opportunities in one
language, thus developing at least one language system instead of developing none. Although
these two underlying assumptions at first appear to have some face value, there is no evidence
to suggest that children with severe disabilities are unable to successfully become bilingual (Ohashi
et al., 2012; Wharton, Levine, Miller, Breslau, & Greenspan, 2000). Additionally, restricting
language input to one language may result in consequences that can negatively impact children
with disabilities who come from a bilingual environment (Yu, 2013).
If bilingualism were too cognitively demanding for children with disabilities who have
cognitive/language deficits, it would follow that children with typically developing language skills
would perform below their monolingual peers because of the increased cognitive load of bilingualism.
Yet, the research literature does not point to such increased cognitive demand to being bilingual.
Evidence demonstrates that typically developing bilingual children exhibit similar language
development trajectories as typically developing monolingual children (Petitto et al., 2001).
Bilingual children develop language skills that are distributed across both languages, even though

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 one language is often stronger than the other (Bialystok, 2001). Both languages are interconnected
on various levels, including cognitively and functionally (Abutalebi, Cappa, & Perani, 2005). It would
be difficult to justify restricting treatment or language input to a single language because of an
assumption that important language skills might be present in only L1 or L2 (Kohnert, Bates, &
Hernandez, 1999).
Language of Intervention Studies. One of the difficulties in fighting the misconception
that bilingualism is more difficult for children with communication difficulties is that few treatment
studies have focused directly on language of intervention questions among bilingual children
(E. Thordardottir, 2010). The few studies of children with language impairment consistently
support the use of both languages during intervention (Perozzi & Sanchez, 1992; E. Thordardottir,
2010; E. T. Thordardottir, Ellis Weismer, & Smith, 1997). Perozzi and Sanchez (1992) found that
treating in the home language (Spanish) first followed by treatment in English produced greater
gains in English targets for bilingual children than only treating in English. Supporting the home
language, especially early in intervention, may actually serve to increase English skills.
Likewise, few studies have looked at different languages of intervention with children
with ASD (Lang et al., 2011; Rispoli et al., 2011; Seung, Siddiqi, & Elder, 2006; Summers, Smith,
Mueller, Alexander, & Muzza, 2017). Such studies have targeted the reduction of challenging
behaviors (Lang et al., 2011; Rispoli et al., 2011) and the increase of communication skills (Lang
et al., 2011; Seung et al., 2006; Summers et al., 2017). These studies have each featured single
subject treatment designs. In studies where the reduction of challenging behaviors was targeted,
challenging behaviors occurred significantly more during the English treatment conditions and
less in the L1 (Spanish) conditions (Lang et al., 2011; Rispoli et al., 2011).
Lang et al. (2011) examined the effect of language of intervention on response accuracy in
discrete trial training with a 4-year-old, female, English-Spanish bilingual child with ASD. The
researchers used an alternating treatment, single-subject design. They found that over the course
of 13 sessions, this child consistently responded with higher levels of accuracy when intervention
was provided in Spanish than when it was delivered in English. However, during the initial
assessment, the child appeared to demonstrate equal language abilities in English and Spanish as
measured by verbal productions in each language. Lang et al. cautioned against using only
assessment information to determine the language of intervention. It would be far better to utilize
both languages and see how the child responds to treatment in both languages before selecting
the language of intervention.
In another case study, Seung et al. (2006) examined the treatment of a 3-year-old,
English–Korean bilingual child with ASD, over the course of 2 years. Intervention was provided in
Korean for the first year, after which the language of intervention was gradually transitioned to
English. Over the 2 years of treatment, the child made significant gains in both expressive and
receptive language skills in both languages. The authors concluded that the child benefited from
intervention in his first language before transitioning to English. These results are similar to those
found by Perozzi and Sanchez (1992). Recently, Summers et al. (2017) compared a monolingual
English treatment to a bilingual treatment for two English–Spanish bilingual children with ASD.
Participants made gains in both conditions. The bilingual treatments were both effective in
improving language outcomes and did not harm the child’s language skills.
Although few, the current evidence from intervention studies in bilingual children with
ASD reveals the importance of using the home language in intervention and not using English
only. On the basis of these findings, Jessica explains to her team that she feels that using
Spanish in therapy will not impede his progress in the classroom; rather, it may actually have a
positive effect on his overall language abilities.

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 Team Concern 3: David’s Family Has Already Been Encouraged to Speak Only English at Home to
Help Him Perform Better in the Classroom
Jessica has found that researchers consistently have demonstrated that parents of
bilingual children with ASD are commonly advised to use only English in their home and
during intervention (Jegatheesan, 2011; Kremer-Sadlik, 2004; Wharton et al., 2000; Yu, 2013).
Specifically, parents are told that bilingual language exposure may cause negative effects on their
child’s language and communication skills (Jegatheesan, 2011; Kremer-Sadlik, 2004; Wharton
et al., 2000; Yu, 2013). It would follow that they would choose monolingual environments for their
children. Given that English is the language of education in the United States, language exposure
becomes limited to English only.
The main concern with this advice is that it is based on the erroneous assumption that
bilingualism will cause further impairments in children who already have difficulties with language.
These recommendations are troublesome because they may restrict the child’s exposure to
language, restrict the quality of language models, limit social encounters, and inhibit social
and emotional growth (Wharton et al., 2000). As previously demonstrated, this recommendation for
English only is not supported by current research evidence (Cleave, Kay-Raining Bird, Trudeau, &
Sutton, 2014; Feltmate & Raining-Bird, 2008; Hambly & Fombonne, 2012; Kay-Raining Bird et al.,
2005; Lang et al., 2011; Paradis et al., 2003; Perozzi & Sanchez, 1992; Petersen et al., 2012; Rispoli
et al., 2011; Seung et al., 2006; E. T. Thordardottir et al., 1997; Valicenti-McDermott et al., 2012).
Additional concerns with this advice include difficulty for parents in following the advice, increasing
parental stress, and resulting in lack of adequate support for bilingual families as reported in
parent interviews, questionnaires, and surveys (Kay-Raining Bird, Lamond, & Holden, 2012;
Kremer-Sadlik, 2004; Wharton et al., 2000; Yu, 2013).
Regardless of receiving erroneous advice from a professional to only use English with
their child with ASD, many parents report that they are unable, practically, to follow this
recommendation (Kay-Raining Bird et al., 2012; Kremer-Sadlik, 2004; Wharton et al., 2000;
Yu, 2013). Many parents of bilingual children have limited English proficiency. It should be
noted that an English-only language model from a speaker who is not proficient in English is not
only inconvenient for the speaker but also reduces the quality of the language model provided
to a child. Parents also report concerns about the possibility of their child’s acquisition of their
accented English (Yu, 2013). Perhaps, the most critical concern that parents have reported is
that they have felt that their child was excluded from various social interactions and gatherings
when their child was only exposed to English (Kay-Raining Bird et al., 2012; Kremer-Sadlik, 2004;
Yu, 2013). Limiting a child only to English prevents him or her from communicating with other
(typically older) family members, community members, and friends.
Additionally, excluding children from social interactions may have an added negative
impact on their ability to acquire language (Kremer-Sadlik, 2004). Children with ASD already
have deficits in social language skills, so being excluded from social interactions in the family
will only serve to increase these deficits. Often, the most powerful language input for children
is provided in naturalistic contexts (Yu, 2016). Kremer-Sadlik (2004) provided an example from
her study of a rich interaction at dinnertime in a family. Because the child with ASD did not
speak Chinese and the parents could not explain a certain concept in English, an older brother
mediated the conversation to make clarifications for all participants. In the end, the child with ASD
was excluded from a rich discussion and was unable to communicate with his parents due to the
linguistic barrier of not understanding Chinese when that was clearly the main language spoken in
the home.
Parental stress is often exacerbated by attempting or failing to follow the English-only
advice from professionals. Parents with limited English proficiency express more stressful and
unnatural interactions with their child (Wharton et al., 2000; Yu, 2013). Parents of bilingual
children with ASD frequently described more natural, relaxed, and intimate interactions with
their children when they used their native language, not English (Kay-Raining Bird et al., 2012;
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 Wharton et al., 2000; Yu, 2013). Further, not only did parents feel more relaxed during their
interactions with their child but they also acknowledged that the duration of their interactions
increased when they used their native language.
Lastly, parents have reported a lack of adequate support for their bilingual families
(Yu, 2013). Parents of bilingual children with ASD report that they understand and value the
importance of English acquisition for their children, but they may have concerns regarding the
elimination of their native language (Yu, 2013). Parents who reside in highly bilingual areas feel
that bilingualism can increase their child’s opportunities (Kay-Raining Bird et al., 2012). Some
parents reported that they had no choice but to have English-only intervention for their child
due to lack of resources available to them (Kay-Raining Bird et al., 2012). It is true that there is
a shortage of professionals, including SLPs, who can provide services in languages other than
English (Lazewnik, Creaghead, Combs, & Raisor-Becker, 2010; Roseberry-McKibbin, Brice, &
O’Hanlon, 2005). This is especially important for SLPs as American Speech-Language-Hearing
Association (2017) urges their practitioners to show respect for the cultural and linguistic preferences
of their patients and also ethically binds them to be culturally competent and considerate of
cultural and language differences in their practice.
Discussion With the Team
On the basis of these findings in the literature, Jessica explains to her team that she
wants to ensure that David’s parents feel supported in using their home language at home. She
suggests having a conversation with his parents and explaining that the team has read new
information that goes against the initial recommendation of speaking only English in the home
and explaining the possible benefits of continuing to use Spanish in the home. This consultation
will allow David’s family to make an informed decision as his file indicates that Spanish is primarily
spoken in the home presently. Following their discussion, the team agrees with Jessica that treating
in both languages is the most ethical decision and is supported by current research. The current
evidence does not support a recommendation to parents that they should choose one language for
their children with ASD. Likewise, there is also no evidence that providing services in the home
language or using both languages will cause further detriment to a child’s language skills. Jessica
is encouraged that this discussion has also enlightened her team as to the importance of supporting
the home language for all students, including those students that are not on her caseload.
Recommendations
On the basis of the research reviewed in the case scenario above and in an effort to improve
the services provided to bilingual children with ASD, we propose the following recommendations
to families and professionals who work with bilingual children with ASD. We also propose general
recommendations for increasing training of professionals and improving our knowledge of language
of intervention effects in treatment by expanding the evidence. These current recommendations
are based on the available literature, which, although limited, provides the foundation for evidence-
based practice decisions in the area of selecting language(s) to be used during intervention.
These recommendations will aid professionals who work with bilingual children with ASD to
determine if their practice is aligned with the evidence available at this time. In some cases,
the recommendations may reflect a shift from current practice trends that are not supported by
evidence.
Recommendations to Parents. Recommendations to parents are as follows:
1. Parents should continue to expose their children with ASD to all languages that are
important and needed in their family and community. This practice will ensure that
the child will be able to participate in important interactions and will not be excluded
from their social circles.
2. Parents who are not native English speakers should be encouraged to speak to their
children in their native language to increase the flow, quality, and duration of their
interaction with their children.

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 Recommendations to Professionals Who Work With Bilingual Children With ASD.
Recommendations to professionals are as follows:
1. Multilingual and multicultural considerations and competence during treatment and
assessment of bilingual children with ASD are critical to ensure that the child receives
the best treatment available.
2. The home language should be supported in intervention directly or indirectly.
Every effort should be made to provide treatment in the home language (e.g.,
referring a child to a clinical who does speak the home language, using interpreters
or paraprofessionals to aid in treatment sessions). However, if a culturally or
linguistically competent clinician is not available, indirect methods may be used by
the clinician, such as parent training and collaboration while the clinician provides
treatment in English. If parents do not speak English, an interpreter or paraprofessional
can help the clinician provide the parents with language facilitating techniques to be
used at home. Such practices should be utilized by the SLP to ensure that the child
receives support of their native language.

General Recommendations to Increase Both the Quality of Services and the

Literature About Bilingual Children With ASD. The following are some general recommendations
to increase both the quality of services and the literature about bilingual children with ASD:
1. As bilingual populations continue to grow in the United States, it is increasingly
important to address the need for more culturally and linguistically competent clinicians.
2. Future research should include treatment studies that determine which language(s)
are most effective in the treatment for bilingual children with ASD.

Conclusion
As erroneous assumptions provided by professionals to families of children with ASD are
challenged and rectified, these children will experience language more naturalistically. Family
practices will be supported with the child, a participant in the social interactions of the family.
More research in the area of bilingual children with ASD will also increase the quantity and
quality of available evidence in making language of intervention decisions. Future work should
focus on testing various methods for including the child’s home language in intervention. Most
importantly, the quality of services to bilingual children with ASD will be improved.

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History:
Received December 05, 2017
Revised February 01, 2018
Accepted February 12, 2018
https://doi.org/10.1044/persp3.SIG14.19

27

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