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Both parents and service providers have voiced concerns about the potential negative impact of exposure to multiple languages on the language and communication skills of autistic children. The current literature review summarized research that assessed the language and communication skills of multilingual autistic children in comparison with their autistic and nonautistic peers. After a comprehensive search, 22 relevant publications were identified that met the inclusion criteria of the current review. Thirteen studies used both direct (directly administered screening/diagnostic tools) and indirect language assessments (e.g. parent questionnaires). Receptive and expressive vocabulary was the most frequently assessed language skill. Available research does not support the assumption that bilingualism has negative effects on the language and communication skills of autistic children. The language and communication skills of multilingual autistic children frequently resembled their monolingual autistic peers in both strengths and areas of growth. Preliminary findings indicate that multilingual autistic children may share some advantages of multilingualism with their multilingual nonautistic peers. Studies often excluded participants with intellectual disabilities or complex communication needs, which means that a large population of autistic children is not yet represented in research about the effects of multilingualism. Keywords autism, bilingualism, communication and language, multilingualism Globally, half of the population is estimated to be bilingual The Pennsylvania State University, USA (Grosjean, 2010). One-fifth of the American population Action Behavior Centers, USA and more than one-third of the Canadian population is Corresponding author: bilingual (Grosjean, 2013). With even higher bilingual Christina Sophia Gilhuber, Department of Educational Psychology, rates for Africa, Asia (Grosjean, 2013), and Europe Counseling, and Special Education, The Pennsylvania State University, (European Commission, 2012), millions of children are 220 CEDAR Building, University Park, PA 16802, USA. educated in a language other than, or in addition to, their Emails: firstname.lastname@example.org; email@example.com 2 Autism 00(0) first language (Grosjean, 2010). The high numbers of Language dimensions and bilinguals and children being raised in multilingual envi- development ronments allow the assumption that a significant propor- Language encompasses spoken, written, and nonverbal tion of children on the autism spectrum are exposed to communication and includes five dimensions: phonology, more than one language. For example, Trelles and Castro morphology, semantics, syntax, and pragmatics (Kortmann, (2019) estimated that up to 25% of children on the autism 2005). The dimension of phonology (including phonetics) spectrum grow up in bilingual environments. is concerned with the sounds of a language and their pro- Language skills in children on the autism spectrum duction, perception, and function (Skandera & Burleigh, encompass a spectrum of unique abilities ranging from 2016). The dimensions of language also include morphol- complex communication needs to typical development ogy (i.e. meanings of internal structures of words), seman- (Hudry et al., 2010). For this reason, both parents and pro- tics (i.e. meanings of words, phrases, and sentences), and fessionals have voiced concerns about the effects of bilin- syntax (i.e. principles that govern the construction of gual exposure on the language development of children on phrases and sentences; Kortmann, 2005; Skandera & the autism spectrum (e.g. Kremer-Sadlik, 2005). The Burleigh, 2016). The dimension of pragmatics involves available research on the language and communication how individuals utilize and adapt language within social skills of autistic children shows that bilingualism appears and cultural contexts (Bornstein et al., 2014; Gleason, to have no adverse effects on children’s language and com- 2017). Social pragmatic development extends beyond spo- munication skills (e.g. Yu, 2016). The current review aims ken language and includes nonverbal and preverbal skills to synthesize (a) which dimensions of language (phonol- such as eye contact (Carbone et al., 2013), communicative ogy, morphology, semantics, syntax, pragmatics) have gestures (Franchini et al., 2018; Smith et al., 2018), turn- been investigated so far and how the language and com- taking (Edmister & Wegner, 2015), and joint engagement munication skills of multilingual children on the autism (Kasari et al., 2006). spectrum have been assessed, and (b) how the language The first few years of a child’s life contain significant and communication skills of multilingual children on the language developmental milestones. Nonverbal communi- autism spectrum compared with their peers. Specifically, cation and communicative intent begin to develop before we examined the extent to which the language skills of the first words are typically voiced around 12 months multilingual children on the autism spectrum resemble (Tager-Flusberg et al., 2005). Around 18–20 months, chil- those of their monolingual peers on the autism spectrum dren usually start combining words to form two-word and to what extent they resemble the skills of their nonau- phrases (Fenson et al., 1994). Semantic and syntactic tistic multilingual peers. In the current review, we identi- development consistently progresses further in the follow- fied 22 group comparison studies that were published prior ing years (Tager-Flusberg et al., 2005). to January 2022. Language and communication skills in Multilingualism children on the autism spectrum Definitions of multilingualism and bilingualism vary (Cenoz, 2013). Bilingualism is the use of multiple lan- While language skills are no longer part of an autism diag- guages or dialects in daily life (Grosjean, 2013; Petersen nosis, according to the fifth edition of the Diagnostic and et al., 2012). In addition, bilingualism is defined based on Statistical Manual of Mental Disorders (DSM; American different factors, including proficiency and exposure Psychiatric Association [APA], 2013), autistic individuals (Surrain & Luk, 2017). Bilingual exposure varies greatly, show high heterogeneity in their language profiles (e.g. including differences in age and amount of exposure (Luk Tager-Flusberg, 2006). Children on the autism spectrum & Bialystok, 2013). Regarding the age of exposure, display a wide range of verbal and nonverbal skills (Noens researchers generally distinguish between simultaneous & van Berckelaer-Onnes, 2005), including significant lan- and sequential bilinguals (Paradis et al., 2021). guage delays (Weismer et al., 2010), language regression Simultaneous bilinguals are exposed to two languages dur- (Lord et al., 2004), and deficits in social pragmatic skills ing their infant and toddler years, while children exposed such as joint attention (Warreyn et al., 2005) and figurative to a second language after their third birthday are typically speech (Baird & Norbury, 2016). The language develop- referred to as sequential bilinguals (Paradis et al., 2021). ment of children on the autism spectrum can present with The regular use of more than two languages is generally difficulties in both receptive and expressive language skills described as multilingualism (e.g. European Commission, (Hudry et al., 2010). Hudry and colleagues found that (a) 2007). In the current review, the term multilingualism will children on the autism spectrum performed below age be used to include individuals who speak two languages as norms, and (b) the development of receptive language skills well as those who speak more than two languages. was generally more delayed than expressive language skills. Gilhuber et al. 3 In addition, speech development varies significantly Another common occurrence in bilinguals’ communi- among autistic children and has been found to be both cation patterns is what is known as code-switching or delayed and divergent from common milestones (Gerenser code-mixing (Paradis et al., 2021), which is the alternating & Lopez, 2017). Prevalence estimates indicate that use of two languages within the same conversation or even approximately 30% of individuals on the autism spectrum the same utterance (Genesee, 2003; Kaushanskaya & do not acquire functional phrase speech (Anderson et al., Crespo, 2019; Wei, 2000). Code-switching is a natural 2007; Wodka et al., 2013). occurrence in bilingual settings, not interference between While autistic children have been found to score lower languages (Kroll et al., 2012). Available evidence also on language and communication assessments than nonau- indicates that syntactic rules of different languages, such tistic controls on a group level, language profiles are highly as word order, are rarely confused by bilingual children heterogeneous (e.g. Tager-Flusberg, 2006). Therefore, lan- (Beauchamp & MacLeod, 2017). guage and communication skills across different domains Language development for sequential bilinguals is should be assessed not only for monolingual children but more individualized than the language development of also for multilingual children on the autism spectrum. simultaneous bilinguals and is influenced by various fac- tors (Paradis et al., 2021). Internal factors, such as age of acquisition and personality, and external factors, such as Multilingual language development amount and quality of second language exposure, influ- Lexical development generally happens at a similar pace ence second language development (Paradis et al., 2021). for monolingual and bilingual children (Genesee, 2003; In general, both quality and quantity of language input Petitto et al., 2001). Early developmental milestones like have been found to predict language acquisition in bilin- babbling and first words emerge at a similar timeline for gual children (Paradis, 2018). Language environments, simultaneous bilingual children and monolingual children therefore, play an important role in bilingual language in at least the bilingual children’s dominant language development (Paradis, 2018). (Paradis et al., 2021). The timeline for sequential bilingual The American Speech-Language-Hearing Association’s children’s non-dominant language development may differ (ASHA; 2004) guidelines for the assessment of bilingual (Paradis et al., 2021). This connects to the fact that lan- children by speech-language pathologists state that in guage development is dependent on both quality and quan- addition to language use, language proficiency should be tity of language input (Paradis et al., 2021). measured in each language. Two-language approaches The effect of bilingualism on phonetic processing and have been found to provide a more accurate reflection of phonological acquisition depends on the conformities of bilingual speakers’ proficiency than single-language the linguistic profiles of the two languages (Havy et al., assessments (e.g. Peña et al., 2016). Core et al. (2013) 2016). In addition to the phonological level, cross-linguis- have also criticized single-language comparisons as inac- tic transfer across the languages of multilingual speakers curate reflections of the true language skills of bilingual also occurs for the language dimensions morphology, children and have suggested the use of total vocabulary semantic, and syntax (McLeod et al., 2017). scores (the sum of words known across both languages) as Simultaneous bilinguals develop their languages nei- opposed to conceptual vocabulary scores, wherein the con- ther in perfect synchrony nor in isolation (Paradis et al., cept of a word counts representatively for both languages 2021). The interdependence of the development of both or single-language comparisons. For this reason, in the languages of simultaneous bilinguals may be why the current review, we coded the included publications for the overall language development of this population is not sig- languages that were assessed as well as the type of nificantly delayed compared with their monolingual peers assessment. (Paradis et al., 2021). In 1989, Grosjean argued that a bilingual is not equal to two monolinguals in one mind. Multilingualism in children on the Research has since found that both languages of bilinguals autism spectrum are constantly activated parallelly, even when activation of only one language is required (e.g. Van Assche et al., Although increasing, research on bilingualism in children 2009). These cross-language interactions have also been on the autism spectrum remains scant to date. In addition found to be bidirectional (Kroll et al., 2015), meaning that to the group comparison studies that have been the focus not only does the first language influence the second lan- of previous reviews (e.g. Drysdale et al., 2015; Lund et al., guage, but vice versa is also true in proficient bilinguals 2017), there are single-case studies investigating different (Dussias & Sagarra, 2007; Van Hell & Dijkstra, 2002). It is aspects of bilingualism in autistic children (e.g. Aguilar hypothesized that controlling the constant competition et al., 2016; Seung et al., 2006; Yu, 2016). In a single-case between two languages may lead to bilinguals performing study of a 5-year-old bilingual boy on the autism spectrum, better on executive functioning tasks (Kroll et al., 2012). Yu (2016) found that a child strategically used 4 Autism 00(0) code-switching to switch between Mandarin and English perspective of their multilingualism. Specifically, those depending on the demands of context as well as personal who were educated in multilingual settings reflected more preference. Another single-case study found that a 6-year- positively on their multilingualism than their peers who old Spanish–English bilingual on the autism spectrum pre- were educated in monolingual contexts (Howard et al., ferred to receive instruction in Spanish, which was their 2019). home language (Aguilar et al., 2016). For a comprehensive Building on previous reviews (e.g. Drysdale et al., review, see Yu (2018). 2015), the current review also focuses on group compari- Research investigating the effects of monolingual and son studies that investigated how the language and com- bilingual interventions for multilingual children on the munication skills of multilingual children on the autism autism spectrum (e.g. Lang et al., 2011; Summers et al., spectrum compared with their peers. Comparison groups 2017) is scant. Lang et al. (2011) compared the effects of include monolingual autistic children, multilingual nonau- providing intervention in both languages of a bilingual tistic children, and monolingual non–autistic children. child on the autism spectrum and reported more positive Previous literature reviews on this topic have concluded effects on response accuracy and behavior when the inter- that existing research does not support the concern that vention was provided in the home language. Summers bilingual exposure might have any detrimental effects on et al. (2017) compared a monolingual and a bilingual inter- the language and communication skills of autistic children vention in an alternating treatment design for two partici- (e.g. Conner et al., 2020; Drysdale et al., 2015; Garrido pants and concluded that both provided similar benefits. et al., 2021). The current review intends to expand on these A few studies have interviewed parents of autistic chil- findings by investigating to what extent the language and dren who were raised in multilingual environments (e.g. communication skills of multilingual autistic children Howard et al., 2021; Ijalba, 2016; Yu, 2013). Parents of resemble or differ from the skills of both their autistic and multilingual children on the autism spectrum have reported nonautistic peers. In addition, we synthesized the findings that professionals often advised them to speak only one lan- to highlight which aspects of language and communication guage with their child (e.g. Fernandez y Garcia et al., 2012; have been assessed and how. There has been an increase in Kremer-Sadlik, 2005), despite the fact that there is no sci- studies on the topic of multilingualism in autistic children entific evidence to support the clinical recommendation in the past 5 years. Therefore, it is our aim to provide an that a monolingual environment is beneficial for the lan- updated synthesis of group comparison studies between guage development of children on the autism spectrum. On multilingual children on the autism spectrum and their the contrary, advising parents to abandon one of their lan- peers. Aiming to extend previous reviews, we intend to guages during interactions with their child has been found highlight which aspects of language have been assessed to have potentially negative effects on family interactions, and how the language and communication skills of partici- such as parents feeling uncomfortable speaking a non- pants have been evaluated. native language with their child (Fernandez y Garcia et al., 2012); children being excluded from family interactions Purpose of the present study (Kremer-Sadlik, 2005); and interactions being limited with monolingual family members (Jegatheesan, 2011). The purpose of this review was to identify and synthesize Recent studies have reported on the perceptions of mul- peer-reviewed publications on multilingualism in children tilinguals on the autism spectrum regarding their own on the autism spectrum. We sought to answer the follow- experiences. In their study on language profiles and social ing research questions: experiences of autistic adults, Digard et al. (2020) found that 33% of participants identified as bilinguals, and 37% 1. What dimensions of language have been included in reported knowing at least three languages. Participant studies of multilingualism in autistic children, and how responses indicated a positive association between bilin- have they been measured? gualism and social life quality (Digard et al., 2020). On a 2. How do the language and communication skills of related study, Nolte et al. (2021) conducted a qualitative multilingual autistic children compare with multilin- analysis of the survey responses of multilingual autistic gual nonautistic children and monolingual autistic adults and concluded a wide range of diverse language children? experiences among the participants. Participants reported various reasons for learning languages and listed a number 2.1 To what extent do the language skills of multilin- of perceived benefits of being multilingual (Nolte et al., gual autistic children resemble the language skills of 2021). Howard et al. (2019) conducted semi-structured multilingual nonautistic children? interviews with 11 bilingual children and adolescents on 2.2 Are commonly observed language features of autis- the autism spectrum between the ages of 7 and 14. The tic children observed to the same extent in multilingual analysis of the interviews concluded that language envi- autistic children as in monolingual autistic children? ronments have a significant influence on the individual’s Gilhuber et al. 5 could not be determined based on the title, we read the Method abstract. Thirty-three articles required a review of the Protocol and eligibility criteria complete text to assess eligibility. To ensure the reliability A systematic literature review was conducted according to of the eligibility criteria, the first and the third authors the guidelines of the Preferred Reporting Items for independently reviewed the full text of the 33 articles. The Systematic Reviews and Meta-Analyses (PRISMA; Moher inclusion decisions were in 97% agreement between the et al., 2009). To be included in this review, studies had to first and third authors. Any disagreements were solved (a) be published in English and in a peer-reviewed journal; through discussion and consultation with the second (b) be of a quantitative design; (c) include multilingual author. Twenty-two peer-reviewed articles met all eligi- autistic children between the ages of 1 and 12 years; (d) bility criteria and were included in the current review include at least one comparison group (i.e. monolingual (Figure 1). autistic children; multilingual nonautistic children); (e) incorporate at least one language measure. Specifically, Data extraction and coding procedures multilingual children were defined as those who were (a) proficient in two or more languages, (b) exposed to at least The first author coded all 22 articles identified in the cur- two languages regularly, or (c) exposed to each language rent review. The coding forms included (a) study charac- for at least 20% of their lifetime. teristics; (b) participant characteristics; (c) quality of evidence; (d) language measures (e.g. formal assessment); (e) language dimensions (e.g. phonology, pragmatics); and Search (f) study outcomes. Studies were coded for study identifi- We searched the databases ProQuest (ERIC), EBSCO cation criteria (i.e. authors; year of publication; country in (Academic Search Complete, PsycINFO), and Medline which the study was conducted); study design (e.g. group (PubMed). We included all records that were published matching criteria); and participant eligibility criteria (e.g., prior to 8 January 2022, and met the eligibility criteria of exclusion of participants with a co-occurring intellectual this study. The lower bound limit for the publication date disability or complex communication needs). Participant was 2011. demographics were coded for age, gender ratio, age at We conducted the database search choosing to focus on diagnosis, race/ethnicity, nonverbal IQ (NVIQ), languages (a) children on the autism spectrum who (b) spoke or were spoken, time of bilingual language exposure (sequential vs exposed to more than one language. We employed an simultaneous), and occurrence of language regression. advanced search method that included various search Language measures were coded for the type of language terms for both categories. The following search terms were measurement (direct vs indirect) and the language measure included in the first line: (autis* OR asperger* OR ASD itself (e.g. Peabody Picture Vocabulary Test; Dunn & OR PDD-NOS OR “pervasive develop*”). To identify Dunn, 2007), and for which language (first or second lan- multilingual participants, the following search terms were guage) scores were reported. Study outcomes were coded included in the second line: (biling* OR multiling* OR for statistically significant differences in the language and “dual language” OR “second language” OR “heritage communication skills between bilingual children on the language” OR “English language learner” OR “limited autism spectrum and their peers. To ensure inter-rater reli- proficiency” OR ESL OR ELL). We used the AND feature ability for the coding process, the third author was trained to combine the two lines. For some search terms, trunca- in the coding process and independently coded 32% (n = 7) tions were used to include different variations of the term. of the articles included in the current review. Articles were We used database filters to limit the results to peer- randomly selected for inter-rater reliability coding. Once reviewed publications written in English. The first and the the first and third authors completed the independent cod- third author independently conducted the search for each ing, all codes were compared. Overall agreement for the database. Agreement for search results was 100% for all 42 coded items was 97% and ranged from 86% to databases. An ancestry search resulted in the identification 100%. Any disagreements were resolved through of five additional articles. All five articles met all eligibil- discussion. ity criteria and were included in the review. Community involvement Study selection Community members were not involved in this study. The search resulted in the identification of 578 publica- tions. Adding in five articles that were identified through Results lineage search, we identified a total of 583 records. We excluded 252 duplicates and then screened the remaining The current review synthesized 22 quantitative studies 331 publications’ titles. For the records where eligibility with publication dates ranging from 2011 to 2021 6 Autism 00(0) Figure 1. Flow diagram displaying the identification and selection of articles. Note. This figure is minorly adapted from the PRISMA flow diagram (Moher et al., 2009). (Beauchamp et al., 2020; Gonzalez-Barrero & Nadig, Study characteristics 2017, 2019a, 2019b; Hambly & Fombonne, 2012; Hoang The great majority of studies (n = 19) used nonexperimen- et al., 2018; Li et al., 2017; Meir & Novogrodsky, 2019, tal, descriptive research designs in which the researchers 2020, 2021; Ohashi et al., 2012; Peristeri et al., 2020; did not manipulate any variables (Mertler, 2021). Only the Petersen et al., 2012; Reetzke et al., 2015; Sen & Geetha, studies by Sendhilnathan and Chengappa (2020a, 2020b) 2011; Sendhilnathan & Chengappa, 2020a, 2020b; and Siyambalapitiya et al. (2022) included an intervention. Siyambalapitiya et al., 2022; Valicenti-McDermott et al., A majority of the studies (n = 20) were cross-sectional 2013, 2019; Vanegas, 2019; Zhou et al., 2019). All 22 pub- group comparison studies (e.g. Beauchamp et al., 2020; lications included at least one language measure (e.g. Peabody Picture Vocabulary Test; Dunn & Dunn, 2007) Ohashi et al., 2012; Petersen et al., 2012; Vanegas, 2019). and a minimum of one comparison group (e.g. monolin- Zhou et al. (2019) and Siyambalapitiya et al. (2022) were gual children on the autism spectrum). the only longitudinal studies included in the current review. Gilhuber et al. 7 Fifteen studies administered formal assessments and only two studies (Reetzke et al., 2015; Vanegas, 2019) tasks to evaluate participants’ language and communica- reported results related to participants’ phonologic skills. tion skills (e.g. Gonzalez-Barrero & Nadig, 2017; Li et al., Thirteen studies used both direct and indirect measures 2017; Petersen et al., 2012). Other studies retrospectively to assess participants’ language and communication skills analyzed data from medical records (Vanegas, 2019) or (e.g. Ohashi et al., 2012; Peristeri et al., 2020). Direct assess- multidisciplinary evaluations (Valicenti-McDermott et al., ments included direct observations or assessments, while 2013, 2019). indirect language assessments included information reported Twelve of the studies were conducted in North America through a parent questionnaire. Seven studies used only (e.g. Valicenti-McDermott et al., 2019; Vanegas, 2019). direct assessment tools (e.g. Meir & Novogrodsky, 2019, Four studies were conducted, at least in part, in Asian 2020, 2021), and two studies only used indirect assessments countries. In addition, one study occurred in Australia (Hambly & Fombonne, 2012; Reetzke et al., 2015). (Siyambalapitiya et al., 2022), one in Greece (Peristeri Different editions of the Peabody Picture Vocabulary et al., 2020), and all participants in the studies by Meir and Test (PPVT; Dunn & Dunn, 2007) were the most fre- Novogrodsky (2019, 2020, 2021) lived in Israel. quently administered direct assessment tool (n = 8), fol- lowed by the Clinical Evaluation of Language Fundamentals (CELF; Wiig et al., 2013; n = 5). The most Participant characteristics commonly used indirect assessments were the Social Participants’ ages ranged from 1 to 12 years. A total of 82% Communication Questionnaire (SCQ; Rutter et al., 2003; (n = 18) of the recruited participants were 10 years or n = 7) and the VABS (Sparrow et al., 2005; n = 7). Other younger (see Table 1). Gonzalez-Barrero and Nadig examples of indirect assessments were the MCDI (Fenson (2019a), Peristeri et al. (2020), and Vanegas (2019) et al., 2007) and the Children’s Communication Checklist included participants up to 12 years of age. Most of the (CCC; Bishop, 2006), which were each used by two of the participants were male. Participants spoke a variety of lan- included studies. guages, with English, Spanish, and French being the most Twelve studies only reported scores for one language common languages. for multilingual participants, generally for the first lan- A total of 11 of the 22 publications had overlapping par- guage (e.g. Ohashi et al., 2012), societal majority language ticipant samples, which limited the synthesis of the find- (e.g. Zhou et al., 2019), or dominant language (e.g. ings. While the composition of the subgroups was different Gonzalez-Barrero & Nadig, 2019b). Only seven studies for each of the studies, Hoang et al. (2018) and the publica- reported scores for both languages for multilingual partici- tions by Gonzalez-Barrero and Nadig (2017, 2019a, pants (see Table 1). In addition to reporting scores for par- 2019b) drew their participants from the same larger study. ticipants’ dominant and non-dominant language, Hambly The two publications by Sendhilnathan and Chengappa and Fombonne (2012) also reported participants’ concep- (2020a, 2020b) were based on the same study and included tual vocabulary scores. Petersen et al. (2012) only reported the same participants. Based on the description of partici- scores for the societal language (English) and not for the pant recruitment, there was also a significant overlap in participants’ home language but also reported total and participants in the publications by Valicenti-McDermott conceptual vocabulary scores. Valicenti-McDermott et al. et al. (2013, 2019) and Meir and Novogrodsky (2019, (2013, 2019) only reported results for communicative 2020, 2021). measures. Language assessment and the representation Comparison of the language and of the five dimensions of language communication skills of multilingual children on the autism spectrum and their peers The 22 studies included in the current review assessed dif- ferent dimensions of languages and different skills within Eleven studies compared the scores of multilingual autistic these dimensions. Semantic-related skills, such as vocabu- children only with their monolingual autistic peers (e.g. lary scores, were the most frequently reported dimension Ohashi et al., 2012; Petersen et al., 2012; Reetzke et al., of language (n = 18). A total of 62% of the studies (n = 13) 2015). Nine studies (e.g. Beauchamp et al., 2020; Meir & reported scores for expressive or receptive vocabulary Novogrodsky, 2021) compared four different groups of (e.g. Vanegas, 2019; Zhou et al., 2019). Eight studies participants: monolingual autistic children, multilingual reported assessments of syntactic skills, such as sentence autistic children, monolingual nonautistic children, and repetition (e.g. Hoang et al., 2018). Seven studies assessed multilingual nonautistic children. The publication by morphological skills (e.g. Gonzalez-Barrero & Nadig, Hambly and Fombonne (2012) was the only study that 2019a). Four studies assessed pragmatic-related skills (e.g. reported scores separately for simultaneous and sequential Hambly & Fombonne, 2012; Reetzke et al., 2015), and bilinguals in comparison with monolingual autistic 8 Autism 00(0) Table 1. Study characteristics. Publication N Gender Age range Country Group matching technique Language Type of language Language assessment Assessed dimensions Assessed ratio (M:F) (years) exposure assessment of language languages Beauchamp et al. 39 n/s 6;0–9;0 Canada Not matched SIM Direct, indirect PPVT-IV, ÉVIP-II, CELF-5, Semantics L1, L2 (2020) CELF-CF, SCQ, M-BLUE Gonzalez-Barrero and 52 44:8 5;0–10;0 Canada Age, NVIQ n/s Direct, indirect PPVT, CELF-IV, CELF-CF, Semantics L1 Nadig (2017) SCQ a b Gonzalez-Barrero and 40 32:8 6;0–9;0 Canada Age, NVIQ, dominant language , SIM, SEQ Direct, indirect PPVT-IV, ÉVIP, TVIP, Syntax, semantics DL Nadig (2019b) maternal education CELF-IV, CELF-CF, SCQ Gonzalez-Barrero and 26 22:4 4;9–10;8 Canada Age, NVIQ, dominant language, maternal n/s Direct PPVT-IV, ÉVIP, TVIP, Morphology, semantics DL, NDL Nadig (2019a) education CELF-IV, CELF-CF, SCQ Hambly and 75 n/s 3;0–6;6 Canada n/s SIM, SEQ Indirect VABS-II, MCDI, ADI-R, LEISemantics, pragmatics DL, NDL, Fombonne (2012) CV a a a b Hoang et al. (2018) 20 15:5 M: 8;1 Canada Age , NVIQ , autism symptomatology , n/s Direct, indirect CELF, CELF-CF, EVIP, Syntax, semantics, DL a a vocabulary ability , maternal education SCQ pragmatics Li et al. (2017) 67 53:14 M: 8;3–9;2 Japan, Age, Raven Colored Progressive SIM Direct, indirect PPVT-IV, PVT-R, CCC-2 Semantics L1, L2 Canada, Matrices scores United States Meir and Novogrodsky 85 49:36 4;0–9;0 Israel Age, NVIQ, heritage language SIM, SEQ Direct Pronoun elicitation task, Morphology, syntax SL (2019) LITMUS SRep-30, ADOS Meir and Novogrodsky 86 49:37 4;6–9;2 Israel NVIQ, SES SIM, SEQ Direct LITMUS SRep-30, LITMUS Morphology, syntax, DL, SL (2020) CLT, FWD, BWD, ADOS semantics Meir and Novogrodsky 92 56:36 4;6–9;2 Israel n/s SIM, SEQ Direct LITMUS SRep-30, LITMUS Morphology, syntax DL, SL (2021) CLT, ADOS-2 Ohashi et al. (2012) 60 49:11 2;0–4;4 Canada Age, NVIQ SIM Direct, indirect PLS-4, ADOS, VABS-II, Semantics L1 ADI-R Peristeri et al. (2020) 80 80:0 7;3–12;0 Greece Age SIM Direct, indirect Picture naming test, Semantics, syntax SL Sentence repetition task, ENNI Petersen et al. (2012) 28 26:2 3;7–6;1 Canada Age SIM Direct, indirect PPVT, PLS-3, PCDI, CDI, Semantics SL, TV, CV CCDI Reetzke et al. (2015) 54 43:11 3;9–8;2 China n/s SIM, SEQ Indirect CCC-2, SRS, ALEQ, SCQ, Phonology, DL LEI morphology, syntax, semantics, pragmatics Sen and Geetha (2011) 15 8:7 4;0–10;0 India Language age, SES n/s Direct LPI Hindi, ELTIC Semantics, morphology, L1, L2 syntax Sendhilnathan and 40 29:11 4;0–6;11 Singapore Age n/s Direct AEPS, Mean length of Morphology, semantics L1 or L2 Chengappa (2020a) utterance Sendhilnathan and 40 29:11 4;0–6;11 Singapore Age n/s Direct AEPS Pragmatics L1 or L2 Chengappa (2020b) (Continued) Gilhuber et al. 9 Table 1. (Continued) Publication N Gender Age range Country Group matching technique Language Type of language Language assessment Assessed dimensions Assessed ratio (M:F) (years) exposure assessment of language languages Siyambalapitiya et al. 120 98:22 M: 3;7 Australia Chronological age, nonverbal n/s Direct, indirect SCQ, VABS-II, MSEL Receptive/ expressive SL (2022) developmental quotient, time between language (n/s) a a assessments , gender , previous language intervention , childcare attendance a a prior study entry , adults in household , children in household , number of younger/older siblings , child medication use b c Valicenti-McDermott 80 n/a M: 2;2 United n/s n/s Direct, indirect RITLS, clinical observation, Semantics n/a et al. (2013) States VABS b c Valicenti-McDermott 462 369:93 1;0–6;0 United n/s n/s Direct, indirect Clinical observation, n/s n/a et al. (2019) States VABS, parent survey Vanegas (2019) 31 24:7 3;0–12;0 United n/s n/s Direct, indirect ROWPVT, EOWPVT, Phonology, semantics SL States PPVT, EVT, VABS Zhou et al. (2019) 37 21:16 Baseline: United Age, NVIQ n/s Direct, indirect MSEL, VABS-II, MCDI Semantics SL 1;0–2;2 States Note. SIM: simultaneous; L1: first acquired language; L2: second acquired language; NVIQ: nonverbal IQ; n/s: not specified; SEQ: sequential; DL: dominant language; NDL: non-dominant Language; CV: conceptual vocabulary; SL: societal language; SES: socioeconomic status; TV: total vocabulary scores. Language assessment: PPVT-IV: Peabody Picture Vocabulary Test, 4th edition; ÉVIP-II: Évaluation de vocabulaire en image Peabody, 2nd edition; CELF-5: Clinical Evaluation of Language Fundamentals, 5th edition; CELF-CF: Clinical Evaluation of Language Fundamental-Version Canadienne Française; SCQ: Social Communication Questionnaire; M-BLUE: Montréal Bilingual Language Use and Exposure; PPVT: Peabody Picture Vocabulary Test; CELF-IV: Clinical Evaluation of Language Fundamentals, 4th edition; ÉVIP: Évaluation de vocabulaire en image Peabody; TVIP: Test de Vocabulario en Imagenes Peabody; VABS-II: Vineland Adaptive Behavior Scales, 2nd edition; MCDI: MacArthur- Bates Communicative Development Inventory; ADI-R: Autism Diagnostic Interview-Revised; LEI: Language Environment Interview; PVT-R: Picture Vocabulary Test—Revised, Japanese Version; CCC-2: Children’s Communication Checklist–2; LITMUS SRep-30: LITMUS Sentence-Repetition task; ADOS: Autism Diagnostic Observation Schedule; LITMUS CLT: LITMUS Cross-linguistic lexical task; FWD: Hebrew Forward Digit Span of the Wechsler Intelligence Scale for Children; BWD: Hebrew Backward Digit Span of the Wechsler Intelligence Scale for Children; ADOS-2: Autism Diagnostic Observation Schedule, 2nd edition; PLS-4: Preschool Language Scale, 4th edition; ENNI: Edmonton Narrative Norms Instrument; PLS-3: The Preschool Language Scale; PCDI: Putonghua Communicative Development Inventories; CDI: Communicative Development Inventories; CCDI: Chinese Communicative Development Inventories; SRS: Social Responsiveness Scale; ALEQ: Alberta Language Environment Questionnaire; LPI Hindi: Linguistic Profile Test Hindi; ELTIC English Language Testing for Indian Children; AEPS: Assessment, Evaluation, and Programming System for Infants and Children; MSEL: Mullen Scales of Early Learning; RITLS: Rossetti Infant-Toddler Language Scale; VABS: Vineland Adaptive Behavior Scales; ROWPVT: Receptive One-Word Picture Vocabulary Test; EOWPVT: Expressive One-Word Picture Vocabulary Test; EVT: Expressive Vocabulary Test. Indicates that this group matching technique could not be applied to all participants. Indicates that the indirect measure was a parent report. Only (nonverbal) communicative measures were reported. 10 Autism 00(0) children. The study by Sen and Geetha (2011) was unique degrees. Findings related to semantics (e.g. vocabulary because they separated the monolingual participants into scores) were most frequently reported. The most underre- two groups according to their language (Hindi, English). ported language dimensions were phonology and prag- The most common group matching criteria were age and matic-related skills, including nonverbal and preverbal nonverbal IQ. communication skills. As pragmatic-related skills are fre- We coded and analyzed the language and communica- quently an area of difficulty for children on the autism tion skills reported in the 22 studies. Out of the core areas spectrum, this gap in research is particularly concerning. of linguistics (Skandera & Burleigh, 2016), the reviewed Most studies (n = 13) used direct and indirect measures publications most frequently assessed semantics (n = 18) to assess language and communication skills. The combi- and syntax (n = 8). The most frequently evaluated skill was nation of direct and indirect measures provides a more vocabulary scores (n = 13). For example, Hambly and accurate reflection of children’s language and communica- Fombonne (2012) found that bilingual children generally tion skills, as direct assessments generally only capture presented with significantly smaller vocabularies in their one moment, frequently in clinical environments. In con- second language and often had not achieved phrase-level trast, parent assessments can provide a more longitudinal speech in their second language. reflection of natural settings. Phonetics and phonology-related skills were only The 22 studies synthesized in this review employed a reported indirectly by Vanegas (2019) and Reetzke et al. variety of assessment tools, for example, the PPVT (Dunn (2015). Reetzke et al. (2015) reported scores for the speech & Dunn, 2007) and the SCQ (Rutter et al., 2003). However, subcategory of the CCC-2 (Bishop, 2006) but did not sepa- only seven studies reported bilingual participants’ lan- rately analyze these scores. Vanegas (2019) found no effect guage and communication scores for both languages. In of bilingualism on phonemic awareness in children on the concurrence with other publications (e.g. MacSwan & autism spectrum. Rolstad, 2006), Meir and Novogrodsky (2020) argued that Seven studies specifically assessed morphological inadequate assessment tools could lead to misrepresenta- skills. For example, Meir and Novogrodsky (2019) tion of the language abilities of multilingual children. Meir assessed pronoun use as one measure of morphosyntax. and Novogrodsky also discussed that had they tested bilin- Gonzalez-Barrero and Nadig (2019a) found no significant gual children in both languages (i.e. their dominant lan- differences between monolingual and bilingual children guage and the societal language), there might have been a on the autism spectrum regarding morphological skills. bilingual advantage. This hypothesis aligns with the criti- Sentence repetition was frequently used (n = 7) to assess cism of the inaccuracy of single-language measures for syntactic abilities (e.g. Peristeri et al., 2020). Pragmatic multilingual populations (e.g. Core et al., 2013). Out of the measures were assessed by only four studies (e.g. Hoang included studies, only Petersen et al. (2012) reported total et al., 2018). Regarding nonverbal communication, and conceptual vocabulary scores, and Hambly and Valicenti-McDermott et al. (2013) analyzed communica- Fombonne (2012) reported conceptual vocabulary scores. tive measures, including pointing, gesturing, and making Future studies should include total vocabulary scores to eye contact, and found a bilingual advantage in some of reflect the most accurate multilingual language skills the measures. Zhou et al. (2019) found that bilingual chil- assessment method. dren started with lower gesture use but made greater gains over time than their monolingual peers. Impact of multilingualism on language and communication skills Discussion The studies analyzed in this review did not provide enough The current review aimed to answer two main research evidence to allow conclusions about the impact of bilin- questions: (a) What dimensions of language have been gualism on the phonetic and phonological skills of autistic included in studies of multilingualism in autistic children children. Regarding morphology, the reviewed research and how they have been measured, and (b) How the lan- has identified multiple differences between morphologic guage and communication skills of multilingual autistic skills of autistic children and their nonautistic peers children compared with the skills of multilingual nonautis- (Gerenser & Lopez, 2017). Meir and Novogrodsky (2019) tic children and monolingual autistic children. found that nonautistic children generally outperformed their autistic peers on morphological tasks. No significant differences, however, were found between monolingual Dimensions of language and language and bilingual autistic children (Gonzalez-Barrero & Nadig, measurement 2019a; Meir & Novogrodsky, 2019). The 22 publications included in the current review Findings on receptive and expressive vocabulary skills addressed the five dimensions of language (phonology, of bilingual autistic children were contradictory. Four stud- morphology, semantics, syntax, and pragmatics) to varying ies concluded that there were no significant differences in Gilhuber et al. 11 vocabulary scores between monolingual and bilingual chil- characteristics with their monolingual autistic peers, dren in both the autistic and nonautistic participant groups including deficits in morphological (e.g. Meir & (Gonzalez-Barrero & Nadig, 2017; Ohashi et al., 2012; Novogrodsky, 2019) and pragmatic skills (e.g. Hoang Petersen et al., 2012 & Vanegas, 2019). Other studies et al., 2018). To date, studies have not assessed whether reported that bilingual children scored lower on both recep- common bilingual phenomena such as code-switching tive (Gonzalez-Barrero & Nadig, 2019a; Hoang et al., (Paradis et al., 2021) and typical autism characteristics 2018; Meir & Novogrodsky, 2020) and expressive (Peristeri such as echolalia are equally common in bilingual children et al., 2020) vocabulary scores compared with their mono- on the autism spectrum as they are in the language of their lingual peers. However, this may be due to the use of sin- peers. gle-language comparisons (Core et al., 2013) instead of In summary, included publications varied significantly total vocabulary scores. In total, only three studies regarding terminology, eligibility criteria, group matching, (Beauchamp et al., 2020; Hambly & Fombonne, 2012; and represented languages. Many studies excluded chil- Meir & Novogrodsky, 2020) reported vocabulary scores for dren with a co-occurring intellectual disability, children both languages of bilingual participants. Again, future who were exposed to more than two languages, and par- research should include assessment methods in both lan- ticipants with complex communication needs. The partici- guages of bilingual participants in order to accurately pant data indicate that the few publications on measure vocabulary development and skills. Doing so will multilingualism in children on the autism spectrum do not allow for more valid comparisons across groups. encompass the whole autism spectrum. This limits the Echolalia, the immediate or delayed reproduction of generalizability of the findings that were synthesized in the utterances (Grossi et al., 2013), is a common behavioral current review. characteristic of autism (APA, 2013). Echolalia was not addressed by any study included in this review, which is of Additional implications, recommendations for particular importance considering that sentence repetition future research, and limitations was frequently used to assess syntactic skills (e.g. Peristeri et al., 2020). Other syntactic skills where bilingual effects There are indications of positive effects of bilingualism, have been observed, such as syntactic parsing (e.g. Dussias for example, in verbal fluency (Gonzalez-Barrero & & Sagarra, 2007), have not yet been assessed in bilingual Nadig, 2017). Seemingly negative effects of bilingualism, children on the autism spectrum. such as lower scores on syntactic abilities, generally Social communication difficulties are a main diagnostic became insignificant when analyses controlled for vocabu- criterion for autism (APA, 2013); however, only a few stud- lary scores (e.g. Meir & Novogrodsky, 2020). This finding ies included pragmatic and nonverbal skills. Joint attention, aligns with previous studies on multilingual children (e.g. an early developmental milestone frequently delayed in Komeili & Marshall, 2013; Meir, 2017). In summary, the children on the autism spectrum (APA, 2013), was one of available evidence does not support the hypothesis that the few preverbal skills assessed by the studies included in multilingualism poses unique barriers to the language and this review. Three studies (Hambly & Fombonne, 2012; communication development of children on the autism Ohashi et al., 2012; Peristeri et al., 2020) assessed joint spectrum. This is especially important as studies have attention through the Autism Diagnostic Interview-Revised shown that speech-language pathologists, teachers, and (ADI-R; Le Couteur et al., 2003). Hambly and Fombonne other service providers often advise parents of children on (2012) concluded there was no negative effect of bilingual- the autism spectrum not to provide multilingual environ- ism on early social communication skills such as joint ments (Fernandez y Garcia et al., 2012). attention. Other studies reported a bilingual advantage in Many factors influence the language and communica- some communicative measures like gesture use (Zhou tion skills of children on the autism spectrum: Both exter- et al., 2019) and pointing (Valicenti-McDermott et al., nal and internal factors can contribute to a delay in 2013) for bilingual autistic children. Concurringly, a longi- language development (Komeili & Marshall, 2013). Along tudinal single-case study by Seung et al. (2006) reported an with influential factors such as time and amount of expo- increase in nonverbal communication skills, including eye sure (Luk & Bialystok, 2013), changes in the language contact, for the bilingual participant. environment are another possible contributor. Changes in Both differences and similarities have been reported for language exposure over children’s lifetime were only spe- the language and communication skills of multilingual cifically addressed by Hambly and Fombonne (2012). children on the autism spectrum in relation to their peers’ Future studies should include more information regarding skills. Positive effects of bilingualism, similar to the effects exposure and other contextual factors. As a number of that have been reported for nonautistic populations, were studies have investigated cognitive skills, for example, indicated for autistic children on some measures, such as executive functioning (e.g. Li et al., 2017), we want to verbal fluency (Gonzalez-Barrero & Nadig, 2017). highlight that it is important for future research to conduct Multilingual autistic children, however, also shared many a systematic review of cognitive skills of multilingual 12 Autism 00(0) Psychology, 75(4), 594–604. https://doi.org/10.1037/0022- autistic children to extend the findings regarding language 006X.75.4.594 and communication skills. Baird, G., & Norbury, C. F. (2016). Social (pragmatic) commu- No review is without limitations. A central limitation of nication disorders and autism spectrum disorder. Archives the current review is that only group comparisons have of Disease in Childhood, 101(8), 745–751. https://doi. been included. Single-case and qualitative studies, such as org/10.1136/archdischild-2014-306944 interviews, have not been included in the current review. Beauchamp, M. L. H., & MacLeod, A. A. N. (2017). Bilingualism In addition, all studies that met the eligibility criteria of the in children with autism spectrum disorder: Making evidence current review were included, regardless of study quality. based recommendations. Canadian Psychology, 58(3), 250–262. https://doi.org/10.1037/cap0000122 *Beauchamp, M. L. H., Rezzonico, S., & MacLeod, A. A. N. Conclusion (2020). Bilingualism in school-aged children with ASD: A pilot study. Journal of Autism and Developmental Disorders, This systematic review synthesized the findings of 22 50, 4433–4448. https://doi.org/10.1007/s10803-020-04501-8 peer-reviewed articles. Some dimensions of language, Bishop, D. (2006). Children’s Communication Checklist-2 such as syntax and semantics, are represented well in the (CCC-2). Pearson. available research, while other areas, such as phonology Bornstein, M. H., Hahn, C., Putnick, D. L., & Suwalsky, J. T. and pragmatics, are severely understudied. D. (2014). Stability of core language skill from early child- The findings of this review provide no evidence that hood to adolescence: A latent variable approach. Child being exposed to more than one language has any negative Development, 85(4), 1346–1356. https://doi.org/10.1111/ effects on the language and communication skills of autis- cdev.12192 tic children. Multilingual autistic children often have com- Carbone, V. J., O’Brien, L., Sweeney-Kerwin, E. J., & Albert, mon autism characteristics affecting their communication K. M. (2013). Teaching eye contact to children with autism: in a manner similar to their monolingual autistic peers. A conceptual analysis and single case study. Education and Treatment of Children, 36(2), 139–159. https://doi. However, preliminary findings also indicate that bilingual org/10.1353/etc.2013.0013 autistic children may share some advantages of bilingual- Cenoz, J. (2013). Defining multilingualism. Annual Review of ism with their bilingual nonautistic peers. Applied Linguistics, 22, 3–18. https://doi.org/10.1017/ S026719051300007X Declaration of conflicting interests Conner, C., Baker, D. L., & Allor, J. H. (2020). Multiple lan- The author(s) declared no potential conflicts of interest with respect guage exposure for children with autism spectrum disor- to the research, authorship, and/or publication of this article. der from culturally and linguistically diverse communities. Bilingual Research Journal, 43(3), 286–303. https://doi.org Funding /10.1080/15235882.2020.1799885 Core, C., Hoff, E., Rumiche, R., & Señor, M. (2013). Total and The author(s) received no financial support for the research, conceptual vocabulary in Spanish-English bilinguals from authorship, and/or publication of this article. 22 to 30 months: Implications for assessment. Journal of Speech, Language, and Hearing Research, 56(5), 1637– ORCID iD 1649. https://doi.org/10.1044/1092-4388(2013/11-0044) Christina Sophia Gilhuber https://orcid.org/0000-0001-9738- Digard, B. G., Sorace, A., Stanfield, A., & Fletcher-Watson, S. (2020). Bilingualism in autism: Language learning profiles and social experiences. Autism, 24(8), 2166–2177. https:// References doi.org/10.1177/1362361320937845 Drysdale, H., van der Meer, L., & Kagohara, D. (2015). References marked with an asterisk indicate studies included in the review. Children with autism spectrum disorder from bilingual Aguilar, J. M., White, P. J., Fragale, C., & Chan, J. M. (2016). families: A systematic review. 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Autism: The International Journal of Research and Practice – SAGE
Published: Jan 1, 2023
Keywords: autism; bilingualism; communication and language; multilingualism
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