REVIEW ARTICLE
Bilingualism, Executive Function, and the Brain:
Implications for Autism
a n o p e n a c c e s s
j o u r n a l
Celia Romero1
and Lucina Q. Uddin1,2,3
1Department of Psychology, University of Miami, Coral Gables, FL, USA
2Neuroscience Program, University of Miami Miller School of Medicine, Miami, FL, USA
3Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
Keywords: bilingualism, executive function, autism spectrum disorder, cognition, second language
exposure, dual language
ABSTRACT
Autism spectrum disorder (ASD) is associated with marked heterogeneity with respect to the
development of executive function abilities. The bilingual advantage refers to the observation
that individuals who speak two languages perform better on executive function tasks than
monolinguals under some circumstances. There is not yet consensus, Tuttavia, as to whether
this advantage can be reliably demonstrated, nor is there consensus regarding under which
conditions it emerges. Bilingual and monolingual children with ASD have comparable
developmental outcomes, particularly in the areas of core ASD symptoms, cognitive function,
and language. Ancora, despite the potential advantages that bilingualism may confer, clinicians
commonly advise against providing a bilingual environment for children with ASD. The purpose
of the present review is to provide an up-to-date assessment of the limited literature on
bilingualism in children with ASD in order to inform evidence-based practice. Studies suggest a
potential bilingual advantage in ASD in the areas of nonverbal intelligence quotient, adaptive
functioning, and expressive vocabulary. A limited yet growing literature provides preliminary
evidence for enhanced executive function ability in some children with ASD. Taken together,
current evidence suggests that although a bilingual advantage may not be universally present in
typical development, it may manifest under specific circumstances, conferring advantage for
populations in which executive function is compromised. Further work is needed to develop
consistent, evidence-based guidelines around language recommendations for families of
children with ASD and to better understand the cognitive and brain mechanisms giving rise
to the bilingual advantage in clinical developmental populations.
INTRODUCTION
Approximately 1 In 54 children in the United States are diagnosed with autism spectrum dis-
order (ASD; Maenner et al., 2020). ASD is associated with marked heterogeneity with respect
to the development of executive function abilities including planning for future goals, inhibit-
ing maladaptive responses, maintaining and manipulating information in working memory,
and flexibly adapting to changes in the environment (Baez et al., 2020; Banich, 2009). While
Sopra 20% of children in the United States speak a language other than English at home, E
approximately 12 million American children are raised bilingually (Annie E. Casey Founda-
zione, 2018), there remains a lack of evidence to guide clinical practice for parents of children
Citation: Romero, C., & Uddin, l. Q.
(2021). Bilingualism, executive
function, and the brain: Implications for
autism. Neurobiology of Language,
2(4), 513–531. https://doi.org/10.1162
/nol_a_00057
DOI:
https://doi.org/10.1162/nol_a_00057
Received: 2 April 2021
Accepted: 20 settembre 2021
Competing Interests: The authors have
declared that no competing interests
exist.
Corresponding Author:
Celia Romero
celiaromero@miami.edu
Handling Editor:
Angela de Bruin
Copyright: © 2021
Istituto di Tecnologia del Massachussetts
Pubblicato sotto Creative Commons
Attribuzione 4.0 Internazionale
(CC BY 4.0) licenza
The MIT Press
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Bilingualism and executive function: Implications for autism
with ASD regarding language use. This is in part due to unresolved issues with respect to the
cognitive and neural mechanisms supporting the development of bilingualism.
The bilingual experience is thought to have influences beyond language processing; how-
ever, it was initially assumed that these consequences were negative. Despite past assumptions
that learning multiple languages may cause confusion and disruptions in language develop-
ment, current findings demonstrate no differences in language acquisition, proficiency, E
achievement of milestones between monolingual and bilingual typically developing children
(Dai et al., 2018; Hambly & Fombonne, 2012; Petersen et al., 2012; Valicenti-McDermott
et al., 2013). Inoltre, emerging evidence suggests that bilingualism may be associated
with cognitive advantages, particularly within the executive function domain (Gonzalez-
Barrero & Nadig, 2019; Iarocci et al., 2017; Ratto et al., 2020; Sharaan et al., 2021).
Recent research has produced mixed results, with some studies reporting a bilingual advan-
tage and others failing to find significant effects in typically developing children and neuro-
typical adults (Dick et al., 2019; Nichols et al., 2020), and some even reporting a bilingual
disadvantage (Bialystok & Shapero, 2005). It is still unclear whether or not a bilingual advan-
tage for executive function truly exists, and under what conditions it manifests. Nonetheless,
current recommendations for typically developing children are to encourage and support bilin-
gual exposure at home (US Departments of Health & Human Services & Education, 2016).
Despite the potential advantages that bilingualism may confer with regards to executive
function abilities, mixed and limited research exists specific to bilingualism in children with
ASD. This dearth of information leaves clinicians struggling to develop informed recommen-
dations for families of children with this increasingly prevalent neurodevelopmental condition.
The current review aims to summarize what is known about the influence of bilingual expo-
sure on executive function development and related cognitive outcomes in autism in order to
aid clinicians and parents of children with ASD regarding their decision on how many lan-
guages to speak in the home to best support cognitive development. Inoltre, we aim to
provide a brief synopsis of current views on how bilingualism impacts the neural basis of exec-
utive function systems in typical and atypical development.
EXECUTIVE FUNCTION
Research investigating the impact of bilingualism on cognitive development has mainly
focused on executive function. Executive function is an umbrella term used to describe a
set of cognitive processes that govern goal-directed behavior. Generally, executive function
encompasses neurocognitive processes including cognitive flexibility, inhibitory control, E
working memory (Blair, 2016; Diamond, 2013; Garon et al., 2008; McClelland & Cameron,
2012; Miyake et al., 2000). These processes are necessary for flexible problem-solving, selec-
tive attention, ignoring distractions, and retention of information, and ultimately depend on
the integrity of neural networks involving lateral frontoparietal (L-FPN), midcingulo-insular
(M-CIN), and frontostriatal brain networks (Dajani & Uddin, 2015; Mugnaio & Cohen, 2001; Seeley
et al., 2007; Uddin, 2021UN; Zelazo & Lee, 2010). The M-CIN is often referred to as the salience
network or the cingulo-opercular network and includes the bilateral anterior insulae, IL
anterior midcingulate cortex, and subcortical nodes (Uddin, 2021UN; Uddin et al., 2019). IL
L-FPN is also known as the executive control network and includes lateral prefrontal cortices
(PFCs), ventrolateral PFC and inferior frontal junction, the inferior parietal lobule, posterior
inferior temporal lobes, and parts of the midcingulate gyrus (Uddin, 2021UN).
Across development, executive function enables individuals to perform increasingly complex
compiti, and distinctive aspects of executive function reflect different periods of growth (for an
Neurobiology of Language
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Bilingualism and executive function: Implications for autism
overview of executive function development, see Best & Mugnaio, 2010; Garon et al., 2008). During
infancy and preschool, core components of executive function develop and form the foundation
for the development of higher cognitive processes well into adulthood (Garon et al., 2008).
Executive Function in Children With ASD
Executive function skills have been demonstrated to be impaired in children with ASD within
laboratory settings and in daily life activities (Demetriou et al., 2018; C. l. E. Lai et al., 2017);
Tuttavia, the profile of executive function in autism is characterized by considerable hetero-
geneity (Baez et al., 2020; Dajani et al., 2016; Geurts et al., 2014). A recent meta-analysis
demonstrates relatively stable broad executive dysfunctions in ASD (Demetriou et al., 2018)
that have been proposed to make significant contributions to core deficits in ASD, particularly
restricted and repetitive behaviors (RRBs; Mostert-Kerckhoffs et al., 2015). RRBs are considered
hallmark features of ASD and include stereotyped movements, insistence on sameness, E
restricted interests (American Psychiatric Association, 2013). RRB severity is related to cogni-
tive inflexibility in children with ASD (Lopez et al., 2005). Research investigating the neural
circuitry underlying RRBs highlights the role of frontostriatal systems in mediating these behav-
iors (Wilkes & Lewis, 2018).
There is evidence to suggest specific executive function deficits in cognitive flexibility among
individuals with ASD (Baez et al., 2020; Yerys et al., 2015; Yeung et al., 2016), particularly in
younger children (Schmitz et al., 2006; van den Bergh et al., 2014). In ASD, brain abnormalities
have been observed in cortical volume and thickness in frontal and other cortical brain regions
(Frazier & Hardan, 2009; Kemper & Bauman, 1998; Romero-Garcia et al., 2019; Turner et al.,
2016). Atypical brain responses in individuals with ASD while performing executive function
tasks have been extensively documented (Braden et al., 2017; Garic et al., 2019; Hanaie
et al., 2018; Just et al., 2007; Walsh et al., 2019). A recent review of neural mechanisms under-
pinning cognitive inflexibility in autism finds atypical patterns of L-FPN and M-CIN activation
during set-shifting and task-switching executive function tasks (Uddin, 2021B).
The Executive Dysfunction model of ASD proposes a domain-general deficit in executive
functions that widely affects ASD symptoms (Hill, 2004; Pennington & Ozonoff, 1996). IL
model originally implied a relationship between cognitive inflexibility and preservation in
ASD; Tuttavia, to date research has found a wider influence of executive function in ASD
symptomatology, including mental health, disability, social cognition, and quality of life
(May & Kana, 2020). A recent meta-analysis across many brain imaging studies of executive
functions in individuals with ASD found different patterns of frontoparietal activation during
executive function tasks (May & Kana, 2020). The findings highlight neurobiological variations
in executive function network recruitment that may contribute to the development of an
executive dysfunction profile ASD. These results support the executive dysfunction hypothesis
of ASD and suggest that deficient frontoparietal recruitment may underlie executive function
difficulties experienced by individuals with ASD. Individual differences in executive function
profiles between children with ASD are evident; Tuttavia, the factors influencing executive
function development and outcomes in ASD are not fully understood (Demetriou et al.,
2018). Bilingual exposure, currently understudied, may be one of these factors.
PROPOSED MECHANISMS UNDERLYING THE EXECUTIVE FUNCTION
BILINGUAL ADVANTAGE
The concept of a bilingual advantage suggests that individuals fluent in two languages develop
cognitive advantages in the executive function domain. There is no clear consensus about the
Neurobiology of Language
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Bilingualism and executive function: Implications for autism
specific cognitive and neural mechanisms underlying the proposed bilingual advantage in
executive function; Tuttavia, it is hypothesized to be based on neuroplasticity, or the brain’s
adaptivity and formative ability gained via experience throughout one’s life (Bialystok, 2009,
2017). Inhibition and monitoring are posited to be potential cognitive mechanisms conferring
enhanced executive control in individuals with diverse language experiences (Bialystok, 2017;
Bialystok et al., 2012). This model contends that both languages in a bilingual individual’s
repertoire are always active, and there is thus a continual competition for selection. Joint acti-
vation and language switching are significant aspects of bilingual language control implicating
nonverbal cognitive processes in their engagement. In order to manage and resolve competi-
tion between the two languages, bilinguals deploy a network of frontoparietal brain regions
more generally involved in action selection and cognitive control (Carlson & Meltzoff, 2008).
Lifelong experience managing two competing languages imposes demands on the cognitive
system that are not typically utilized for language processing. Subsequently, the brain adapts to
these recurrent demands and reorganizes networks to build more efficient executive control
mechanisms, resulting in cognitive benefits when non-linguistic processing draws on the same
executive control networks (Rodríguez-Pujadas et al., 2013). Since language switching
involves overlapping frontal brain systems involved in executive control and inhibitory pro-
cesses (Coderre et al., 2016), it is proposed that bilingualism may result in the general
enhancement of these control systems in the brain (Bialystok et al., 2012; Hilchey & Klein,
2011). Neural adaptation may occur via change in structural resources or capacity, alterations
in regional efficiency, or fluctuations in network connectivity (Bialystok, 2017).
Adaptations to language control demands in bilinguals are evident in the structural plasticity
of the brain (Burgaleta et al., 2016; Mamiya et al., 2016; Mechelli et al., 2004) and neural activity
modulation (Abutalebi et al., 2012; Anderson et al., 2018; Ansaldo et al., 2015; Bialystok et al.,
2005; Dash et al., 2019; Kousaie & Phillips, 2017; Luk et al., 2010; Morales et al., 2015; Timmer
et al., 2017). Tuttavia, although current research suggests changes in the bilingual brain’s
architecture, the nature and location of the adaptation and brain recruitment vary between
studies (for discussion see García-Pentón et al., 2016).
The adaptive control hypothesis argues that language context is a key determinant of
the impact of bilingualism on executive function and describes three types of interactional
language contexts requiring differing levels of inhibitory control to enable language: single-
language contexts, dual-language contexts, and dense code-switching contexts (Verde &
Abutalebi, 2013). The contexts differ in the extent of demand in language control based on
the presence or absence of both languages and how language interference is resolved. For
esempio, in single-language contexts each language is generally kept apart and is used in sep-
arate distinct environments with infrequent language switching. In a dual language context, both
languages are spoken within the same environment, resulting in frequent switching. In this con-
testo, the need for language control is argued to be high because the production of both languages
is kept separate (Verde, 2018; Verde & Wei, 2014). In a dense code-switching language context,
languages are interchanged within single statements, or words are adapted from one language to
integrate with the other language. The adaptive control hypothesis identifies eight control
mechanisms engaged in the differing bilingual contexts: goal maintenance, conflict monitoring,
interference suppression, salient cue detection, selective response inhibition, task engagement,
task disengagement, and opportunistic planning (Verde & Abutalebi, 2013). Central to this
framework is that similarly to general cognitive control, bilingual language control fluctuates
depending on the environment’s linguistic control demands. Così, the extent to which each
interactional language context requires inhibitory control will determine the magnitude of the
bilingual advantage. Tuttavia, recent research in English-Mandarin young adults has found
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Bilingualism and executive function: Implications for autism
positive and moderately strong correlations between engagement in dual-language context and
dense code-switching context, suggesting fluidity between engagement in the three language
contesti (G. Lai & O’Brien, 2020). Therefore, the model’s distinction of interactional language
contexts may be less pronounced in multilingual environments characterized by prevalent
bilingualism and wide use of multiple languages.
Bilingual Executive Function Advantage in the General Population
Executive function is generally assessed with self- or informant-report questionnaires or
laboratory task-based measures. Studies assessing the relationship between bilingualism and
executive function abilities generally utilize a between-subject design and examine the per-
formance of bilingual and monolingual individuals on tasks including one condition that
demands an aspect of executive function. Classic tasks frequently utilized in these studies
include the dimensional change card sort (Zelazo, 2006), the flanker task (Eriksen & Eriksen,
1974), the Simon task (Simone & Rudell, 1967), the color-shape switching task (Prior & Mac-
Whinney, 2010), and the attention network test (Rueda et al., 2004).
Of all executive function processes, inhibition has been most widely studied. The flanker
and Stroop tasks are thought to measure inhibitory control by inducing cognitive conflict in
slightly different manners. In the Simon task, colored squares are used to induce conflict by a
spatial-stimulus-response mismatch in incongruent trials, whereas, in the flanker task, congru-
ent or incongruent arrays of arrows are utilized to measure resistance to the interference of
flanking distractors. In these tasks, beyond inspecting overall reaction times in the congruent
and incongruent trials, a difference score as an index of inhibitory control is calculated. Com-
parisons of task performance among monolingual and bilingual children demonstrate smaller
costs (Mezzacappa, 2004; Yoshida et al., 2011) or more accurate and faster performance (Yang
et al., 2011) for bilingual children on the incongruent trials. Evidence suggesting bilingualism
enhances aspects of executive function on tasks that require ignoring relevant information,
task switching, and resolving conflict has been championed and replicated many times
(Barac et al., 2014; Bialystok et al., 2012; Costa et al., 2009; Hartanto & Yang, 2020; Kroll
& Bialystok, 2013; Prior & MacWhinney, 2010). Tuttavia, there is no consensus as yet on
the casual relationship between bilingualism and these benefits and whether these benefits
constitute an advantage in real life.
Over the past two decades, numerous studies have tested the bilingual advantage but no
consensus has yet been reached (for meta-analyses and reviews see Donnelly et al., 2019;
Paap, 2019; van den Noort et al., 2019). Bilingualism has been demonstrated to have a pos-
itive effect on executive function in children (Carlson & Meltzoff, 2008; Crivello et al., 2016;
Kempert & Hardy, 2015; Martin-Rhee & Bialystok, 2008); yet, there is a gap in our understand-
ing of the effects of bilingualism on cognitive development outside of the language domain in
both typically developing children and children with neurodevelopmental conditions.
More recently, studies have continued to produce mixed results, with some studies reporting
a bilingual advantage (Hartanto & Yang, 2020) and others failing to replicate these results in
neurotypical adults and typically developing children. Current large-sample studies of neuro-
typical adults and typically developing children do not support the bilingual advantage
hypothesis. A large-sample study (n = 4,524) assessing bilingualism in 9–10-year-old typically
developing children does not support the bilingual advantage hypothesis for inhibitory control,
attention switching, or cognitive flexibility (Dick et al., 2019). Allo stesso modo, Nichols and col-
leagues (2020) find no reliable executive function differences between language groups in
11,041 adults. A recent meta-analysis by Gunnerud et al. (2020) offers limited support for a
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Bilingualism and executive function: Implications for autism
bilingual executive function advantage in 2–14-year-old typically developing children. Mod-
erator analysis conducted by the experimenters shows substantial heterogeneity of true effects
and unexplained heterogeneity in the effect sizes.
Research investigating bilingualism and cognition using functional magnetic resonance
imaging (fMRI) methods in typical populations have also resulted in mixed findings. Limited
existing neuroimaging studies suggesting a bilingual advantage are underpowered, report sta-
tistically nonsignificant differences in executive function task performance across monolingual
and bilingual groups, and fail to directly relate brain activation with behavioral performance
(Costa & Sebastián-Gallés, 2014; Garbin et al., 2010; Mohades et al., 2014). More recently,
DeLuca et al. (2020) suggest that equivalent task performance among language exposure
groups allows for meaningful interpretation of functional neural differences without possible
confounds of behavioral differences. Tuttavia, interpreting bilingualism-induced brain differ-
ences merely from neural activation patterns in the absence of statistically different task-
performance effects may lead to the reverse inference fallacy (Poldrack, 2006).
The presence of a bilingual advantage in non-linguistic processes, particularly within the
executive function domain, have been brought into question by many studies in which differ-
ences between bilinguals and monolinguals cannot be consistently replicated. Literature on
bilingualism and executive function is proposed to be affected by a confirmation bias to report
only positive results (de Bruin et al., 2015; Paap & Greenberg, 2013). Findings suggesting a
bilingual advantage have been debated due to replication failures and claims that they are
simply artefacts of small non-representative sample studies that do not adequately control
for potential confounds (Lehtonen et al., 2018; Paap & Greenberg, 2013; von Bastian et al.,
2016). Definitions of bilingualism differing between authors and fields also contribute to the
conflicting results found in bilingualism research (Luk & Bialystok, 2013). Allo stesso modo, varying
bilingualism parameters including the number of languages known (Schroeder & Marian,
2016), age of acquisition of each language (Johnson & Newport, 1989), proficiency in each
lingua (Perani, 1998), or language-switching habits (Verreyt et al., 2015) influence distinct
neurocognitive processes.
Nonetheless, current research investigating a potential bilingual advantage among neuro-
typical populations aligns with the conclusion drawn from Paap et al.’s (2015) narrative review
suggesting that there is either no bilingual advantage in typically developing children and
neurotypical adults, or it is “restricted to very specific and undetermined circumstances” (Paap
et al., 2015 titolo).
Bilingual Executive Function Advantage May Exist Under Certain Conditions
The extent to which bilingualism confers advantages in the executive function domain in the
general population is still an ongoing topic of debate and warrants further research. Conflicting
findings in the literature have led researchers to argue whether the bilingual executive function
advantage might be restricted to specific groups of individuals or contexts (Bak, 2016;
Bialystok, 2016; de Bruin, 2019). The most robust bilingual advantage claims come from
studies of individuals with executive dysfunction.
Older adults display reduced efficiency of lateral prefrontal control regions and counteract
for age-related declines in executive function task performance by relying on enhanced fron-
totemporal connectivity compared with younger adults (Hakun et al., 2015). The default-
executive coupling hypothesis of aging theorizes that inflexible coupling of the M-FPN and
lateral prefrontal regions underlie worsening performance on executive function tasks and
reduced flexibility (Spreng & Turner, 2019). It has been proposed that while the effects of
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Bilingualism and executive function: Implications for autism
bilingualism may not be present in the general population, lifelong experience managing
multiple languages may confer an advantage later in life when executive functions are
compromised.
In individuals experiencing age-related cognitive decline, a cognitive reserve has been
observed, where the bilingual brain is more resistant to neurodegeneration and dementia
(Schweizer et al., 2012). Approximately 60% of studies in the field demonstrate that lifelong
use of two languages may impart advantages in the executive function domain or delay the
appearance of symptoms associated with cognitive decline and dementia (Calvo et al., 2016).
More recently, a study examining bilingualism using a continuum from passive to active bilin-
gualism, identifies a certain degree of bilingualism that has neuroprotective benefits (Calabria
et al., 2020). The fact that bilingual experience helps offset age-related losses in executive
processes has led to the proposal that bilingualism may act as a neuroprotective factor against
dementia by buffering against the decline in cognitive control abilities typically observed in
later life (Costumero et al., 2020; Dash et al., 2019). Despite equal cognitive decline in mono-
lingual and bilingual groups, studies have found increased brain atrophy in areas associated
with dementia among bilingual individuals, suggesting bilinguals have a higher threshold for
reaching a dementia diagnosis (Duncan et al., 2018; Schweizer et al., 2012). Other studies
suggesting alternative networks where circuits not affected by neurodegeneration play a
compensatory role, demonstrate greater frontoparietal network connectivity (Perani et al.,
2017) and improved functional and neural efficiency within the executive control network
in bilingual older adults (Abutalebi et al., 2014; Borsa et al., 2018; Gold et al., 2013; Del
Maschio et al., 2018).
Similar robust bilingual advantage claims come from studies of children of lower socioeco-
nomic status (SES; Carlson & Meltzoff, 2008; Engel de Abreu et al., 2012; Hartanto et al.,
2019). It is well known that SES affects language development and modulates the development
of executive function skills (Bradley & Corwyn, 2002; Lawson et al., 2018; Mezzacappa,
2004; Noble et al., 2007). Children of lower SES backgrounds perform more poorly on exec-
utive function tasks across development (see Hackman et al., 2015, for a discussion). Behav-
ioral assessment of SES-related executive function differences is bolstered by neuroimaging
evidence revealing differences in brain function and structure associated with executive func-
tion abilities among high and low SES children (Finn et al., 2017; Kishiyama et al., 2009;
Noble et al., 2012; Sheridan et al., 2012, 2017).
Precocious executive function development in bilingual children may help offset SES dis-
advantages (Engel de Abreu et al., 2012; Kempert et al., 2011; Poarch & Bialystok, 2017).
Carlson and Meltzoff (2008) demonstrated that 5–7-year-old bilingual children of lower SES
backgrounds exhibited advantages over monolingual children of higher SES backgrounds on
an assortment of executive function tasks (per esempio., Simon says, visually cued recall, advanced
dimensional change card sort) controlling for parental education as proxy for SES. While a
bilingual advantage emerged only after controlling for SES, the composite raw scores of the
executive function tasks revealed similar performance between lower SES bilingual children
and higher SES monolingual children. These findings suggest that some of the cognitive dis-
advantages associated with lower SES may be compensated by superior cognitive control
mechanisms resulting from bilingual experience. More recently, Naeem et al. (2018) deter-
mined that bilingualism is crucial in promoting speed of processing advantages among eco-
nomically disadvantaged 18–30-year-old adults, but had little impact on individuals with high
SES. Così, bilingualism is hypothesized to protect against cognitive effects associated with
poverty. It is important to note, Tuttavia, that a recent meta-analysis found significant effects
for 2–14-year-old middle-class SES bilinguals, while those with a low and upper-middle SES
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Bilingualism and executive function: Implications for autism
exhibited no bilingual advantage (Gunnerud et al., 2020). Tuttavia, although their overall
mean effect size was relatively small, true variation was identified between studies, suggesting
that a bilingual advantage might be present under specific conditions. Taken together, research
among populations with executive dysfunction (per esempio., children of low SES backgrounds and
older adults) suggests that the bilingual advantage may manifest under these and perhaps other
specific circumstances.
BILINGUALISM IN CHILDREN WITH ASD
Bilingualism in children with ASD is understudied. Currently, there are no specific guidelines
for bilingual families of children with ASD, a neurodevelopmental condition characterized
by difficulties in social and communication skills (Lord et al., 2018). Autism is associated with
marked heterogeneity with respect to the development of spoken language. While some
children do not develop any spoken language, some have a restricted range of verbal com-
munication skills, others experience only subtle differences, and some have superior linguistic
skills (Watson & Flippin, 2008).
Children with ASD also exhibit considerable heterogeneity in executive function abilities
(Baez et al., 2020). This may present complications when learning verbal referents for related
ideas in multiple languages. Theoretically, these executive function difficulties could present
difficulties for children with ASD attempting to learn verbal referents for similar concepts in
multiple languages. Così, many parents (Hampton et al., 2017) and practitioners (Moore &
Pérez-Méndez, 2006) have concerns about raising children with ASD speaking more than
one language. Di conseguenza, parents of children with ASD in the United States are commonly
advised to speak only one language with their children (Baker, 2013; Bird et al., 2012; Harlin
& Paneque, 2006; Yu, 2013, 2016UN). Tuttavia, there is growing evidence that there are no
negative effects of bilingualism on language comprehension, production, reading, or writing
in children with ASD (Bird et al., 2012; Zhou et al., 2019).
There is very little research specific to bilingualism in children with ASD, leaving clinicians
struggling to develop informed recommendations for families of children with the condition.
Research on the effects of raising a child with ASD in a bilingual environment is emerging; still,
the majority of studies have focused on examining only language outcomes. Current literature
demonstrates that infants with ASD, even those with intellectual disability, can acquire second
language vocabulary (Hambly & Fombonne, 2014; Wang et al., 2018). Current literature also
demonstrates that at school-age, 6–9-year-old children with ASD can become proficient
bilinguals and follow similar language development patterns as typically developing bilingual
children (Gonzalez-Barrero & Nadig, 2019).
A small but growing body of evidence shows that children with ASD raised in bilingual
households have equivalent or better language outcomes than children with ASD from mono-
lingual home environments. For instance, there is similar performance in early language mile-
stones between bilingual and monolingual toddlers with ASD (Hambly & Fombonne, 2012;
Valicenti-McDermott et al., 2013). Tuttavia, compared with toddlers with ASD less than
3-years-old reared in monolingual homes, bilingually exposed toddlers with ASD are found
to more frequently use gestures and vocalize, with no other differences in language skills
between the groups (Valicenti-McDermott et al., 2013). Researchers have also demonstrated
that bilingually exposed children with ASD have receptive and expressive language abilities
comparable to monolingual children with ASD (Dai et al., 2018; Petersen et al., 2012).
Tuttavia, 3–6-year-old bilingual children with ASD reportedly have larger total production
vocabularies than children raised monolingually (Petersen et al., 2012). Together, current
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Bilingualism and executive function: Implications for autism
research suggests bilingualism has no detrimental impact on language outcomes for children
with ASD (Bird et al., 2012; Gonzalez-Barrero & Nadig, 2019; Hambly & Fombonne, 2012;
Ohashi et al., 2012; Reetzke et al., 2015; Wang et al., 2018).
Emerging evidence also suggests that children with ASD reared in bilingual households
demonstrate developmental outcomes equivalent to or superior to children with ASD raised
in monolingual homes. For instance, 3–6-year-old children exposed to bilingual environments
from birth demonstrate better parent-reported social interaction skills on the Vineland Adap-
tive Behavior Scales-II interpersonal subdomain than children of the same age exposed after
the age of 3 years (Hambly & Fombonne, 2012). Inoltre, compared with their monolin-
gual peers, bilingual toddlers with ASD do not experience any negative effects in the social
domain (Hambly & Fombonne, 2012; Reetzke et al., 2015) and demonstrate higher adaptive
functioning (Valicenti-McDermott et al., 2013). In terms of symptom severity, the literature
suggests that bilingual children with ASD do not experience any differences in core autism
symptom severity scores as assessed with the Autism Diagnostic Observation Scale, a stan-
dardized diagnostic test for autism (Bird et al., 2012; Hambly & Fombonne, 2012; Ohashi
et al., 2012; Valicenti-McDermott et al., 2013).
Bilingual Executive Function Advantage in Children With ASD
The extent to which bilingualism is associated with enhanced executive function abilities in
developmental clinical populations is debated. Bilingual research in the executive function
domain among individuals with ASD remains sparse. Iarocci et al. (2017) found that 6–16-
year-olds with ASD exposed to a second language experienced reduced clinical impact in
executive function abilities as assessed by the parent informant-report Behavior Rating Inven-
tory of Executive Function (BRIEF; Gioia et al., 2000) in a large sample of 174 children. In their
study, there were no statistically significant differences between bilingual and monolingual
children with ASD on parent-reported executive function outcomes; Tuttavia, bilingually
exposed children with ASD were less likely to have executive function ratings in the clinically
significant range of concern. More recently, Ratto et al. (2020) found that young bilingual
children with ASD (n = 55) were more likely to have significantly reduced parent-reported
executive function difficulties on inhibitory self-control and flexible switching compared with
monolingual children with ASD.
There is a growing but limited body of research examining the performance of bilingual
children with ASD on directly assessed measures of executive function. A recent study inves-
tigating the relationship between bilingualism and executive function abilities in 6–9-year-old
children with ASD with the dimensional change card sort task (DCCS) and the BRIEF parent
report of executive functioning in daily life, found a tentative advantage in cognitive flexibility
among 20 bilingual children with ASD compared with their monolingual peers (Gonzalez-
Barrero & Nadig, 2019). Li and colleagues (2017) found a similar advantage for bilingual
8-year-old children with ASD using tasks assessing inhibitory control including the Stroop task
(MacLeod & Grant, 1991), the Simon task (Simone, 1969), and the go/no-go task (Donders,
1969). More recently, Sharaan et al. (2021) investigated the impact of bilingualism on execu-
tive function domains relevant to the adaptive control hypothesis: sustained attention, infer-
ence control, and flexible switching utilizing the psychomotor vigilance task (Dinges &
Powell, 1985), the Simon task, and the DCCS task respectively. The researchers found an
advantage in sustained attention among bilingual children with ASD ages 5–12 compared with
their monolingual peers with ASD (Sharaan et al., 2021). Together, these findings suggest that
bilingualism does not negatively impact the executive function skills of children with ASD,
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Bilingualism and executive function: Implications for autism
and may even mitigate some difficulties in this domain. Tuttavia, in each study a bilingual
advantage was demonstrated in only one of the outcome variables assessed, and equivalence
performance between bilingual and monolingual children with ASD was observed on all
other executive functions. Therefore, it is still unclear whether these effects are robust and
replicable.
FUTURE DIRECTIONS
Future directions for this area of research include an increased attention to measurement
issues. Laboratory-based measures of executive function tasks may have insufficient predictive
value to actual participant ability in the real world (Crawford, 1998). For instance, UN 30 ms
difference in magnitude performance in the flanker task yields a significant inhibitory control
advantage for bilingual children compared with their monolingual peers (Poarch, 2018);
Tuttavia, it is unclear whether this difference in executive function task performance consti-
tutes an advantage in real life (Poarch & Krott, 2019). Well-documented executive dysfunction
in ASD is not necessarily directly related to executive function deficits assessed experimentally
(Geurts et al., 2009). Inoltre, there is often poor convergence between neuropsychological
and laboratory-based measures of executive function and more ecologically valid assessments
of real-world behaviors (Dang et al., 2020). This is because laboratory-based behavioral mea-
sures index responses during structured situations, whereas informant-report measures probe
how the individual functions in real-life situations. For this reason, it is imperative that future
work include both standardized laboratory-based executive function measures and informant-
based questionnaires that query executive functions in daily life (Uddin, 2021UN).
Despite bilinguals and monolinguals being treated and compared as two uniform and dis-
tinct groups, it is rare that two bilinguals are the same (de Bruin, 2019). There is a broad range
of bilingual profiles that is defined by individual experiences including age of acquisition, pro-
ficiency level, immersion in a bilingual environment, quantity and quality of switching
between languages and so on. Given the absence of a single definition for bilingualism, Esso
is possible to consider bilinguals with different degrees of language proficiency in different
contexts such as school or home and different periods of their lives. Additionally, ASD is asso-
ciated with a wide range of language abilities ranging from restricted to hyperlexic language
abilities (Watson & Flippin, 2008). Nonetheless, current literature mainly reports only two pro-
files of ASD bilinguals: those raised in multilingual environments and those who know and can
use several languages. As such, to date research on bilingualism in ASD does not reflect the
diversity of language history profiles that is largely described in neurotypical populations
(Digard et al., 2020). It is important that future work explore ASD language profile diversity,
provide more information about the language context in which bilingual participants are
immersed, and take into account the individual experiences of bilinguals. There are reliable
assessments of multilingual profiles such as the Language Experience and Proficiency Ques-
tionnaire (Marian et al., 2007) available to provide a comprehensive description of bilingual
participants. Tuttavia, these types of nuanced measures of bilingualism are not yet routinely
used in bilingualism research.
It is also important to note that not all children with ASD exhibit the same profile and sever-
ity of executive function deficits. This heterogeneity makes accurate assessment of ability all
the more critical. Comorbidity with other conditions such as ADHD are very common among
children with a primary diagnosis of ASD (Leitner, 2014). Executive dysfunction is more
pervasive and severe in ADHD (Bloemen et al., 2018). Although not all children with ASD
experience executive function difficulties (Baez et al., 2020), most children with comorbid
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Bilingualism and executive function: Implications for autism
ASD and ADHD exhibit executive dysfunction (Dajani et al., 2016). Tuttavia, the nature and
severity of executive dysfunction can greatly differ across and within children with ASD,
ADHD, or comorbid ASD and ADHD (Uddin, 2021B). Future work must overcome the limited
generalizability of small sample sizes and collect data from children of varied functioning
levels with a range of comorbid conditions to better characterize relationships between
bilingualism and executive function in ASD.
Future directions should explore brain mechanisms supporting putative bilingual executive
function advantages in children with autism to better understand the neural circuitry underly-
ing this phenomenon and understand how bilingualism differently affects the development of
executive function systems in the brain of children with ASD. While a bilingual executive
function advantage has been demonstrated in certain circumstances, the mechanisms that
underlie this advantage remain elusive. Allo stesso modo, it remains unknown to what degree the
development of a bilingual advantage for executive function is sensitive to IQ and age effects
including acquisition age. For instance, a bilingual executive function advantage may only
develop as a result of early exposure where both languages are used and activated in parallel
for a long period of time. Tuttavia, it may also be possible that the acquisition of a second
language later in life is enough to influence executive control mechanisms. Future work
should explicitly study the impact of IQ and developmental effects on the development of a
bilingual advantage for executive function.
The ambiguous state of bilingualism research is not limited to executive function and
extends to other aspects of mental functioning, such as theory of mind, which is commonly
compromised in individuals with ASD (Rosello et al., 2020). Theory of mind is a socio-
cognitive ability that is thought to be closely linked to executive functioning (Devine &
Hughes, 2014). There are a few papers suggesting that bilingualism accelerates theory of mind
development (Diaz & Farrar, 2018; Farhadian et al., 2010; Goetz, 2003; Han & Lee, 2013;
Schroeder, 2018). Future work should continue to explore other cognitive domains in addition
to executive function that bilingualism may influence.
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CLINICAL SIGNIFICANCE
Qualitative research on bilingual children with ASD demonstrates a discrepancy between evi-
dence and instruction given to parents (Bird et al., 2012; Core & Hoff, 2015; Howard et al.,
2021). Despite the fact the bilingualism does not have a negative impact on language devel-
opment for children with ASD and may potentially compensate for executive dysfunction,
practitioners working in the area of communication and language disorders continue to advise
against providing children with developmental disabilities a bilingual environment (Baker,
2013; Bird et al., 2012; Drysdale et al., 2015; Jegatheesan, 2011; Yu, 2013, 2016UN, 2016B).
This may be because bilingualism is still often perceived as entailing a heavy cognitive load
(Park, 2014).
After ASD diagnosis, bilingual children experience a rapid reduction in native language
input, even though the use of the home language is persistent in adult-adult and adult-sibling
interactions. The decision to restrict their bilingual child’s learning environment may have sig-
nificant implications (Howard et al., 2020). For many immigrant families, the use of language
in the home ties to cultural identity and facilitates communication and connectedness with
their child. Language is an element of a community’s foundation and is inherently related
to social development, così, children being denied bilingual input often miss opportunities
for social learning. Parents using their native language with their child better convey emotions,
maintain engagement, and expand on topics (Wharton, 2000). Tuttavia, when parents use
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Bilingualism and executive function: Implications for autism
their non-preferred language during family interactions, they have shortened interactions and
more frequent interruptions (Yu, 2016UN). Additionally, previous research indicates that bilin-
gual parents report that limited second-language proficiency may influence their ability to
interact fluidly with their child (Kremer-Sadlik, 2005). In the absence of evidence that bilin-
gualism is detrimental to children with ASD, advising parents to restrict their bilingual lan-
guage environment, thus altering the quality of interactions, may be problematic.
CONCLUSIONS
The limited research available presents predominantly converging results on the relationship
between bilingualism and executive function advantages in ASD. Developmental outcomes of
bilingual and monolingual children on the autism spectrum are comparable. Recent large-
sample behavioral studies of neurotypical adults and typically developing children do not
support the bilingual advantage hypothesis. Tuttavia, bilingualism may provide cognitive
benefits in specific cases. Per esempio, there is strong evidence that bilingualism acts as a
protective factor and may buffer against cognitive decline and dementia. Likewise, bilingual-
ism can bolster executive function in young children, particularly of low SES. And finally, there
is preliminary evidence suggesting that bilingualism may ameliorate executive function diffi-
culties in some children with ASD. This research in cognitive development and aging thus
suggests that bilingualism might confer an advantage when executive function abilities are still
developing, or in clinical populations where executive function is compromised. Così,
bilingualism, under the right conditions, may act as a protective factor for certain executive
function difficulties.
The current review identified several topics that need to be addressed in future research.
Firstly, the use of standardized objective proficiency measurements is strongly recommended.
Measurement issues complicate the assessment of executive function difficulties and their neu-
ral basis as different combinations of laboratory-based measures, neuropsychological tests,
and informant-reports have been used across studies. Future directions should include
addressing these issues of measurement in order to maximize ecological and construct validity
in research on the relationship of executive function and bilingualism. Secondly, detailed
descriptions of the bilingual participants are necessary and individual differences should be
better accounted for. Further work is needed to explore heterogeneity and comorbidity in
order to better characterize relationships between bilingualism, executive function, and its
neural representation in ASD.
AUTHOR CONTRIBUTIONS
Celia Romero: Conceptualization: Equal; Writing – original draft: Lead; Writing – review &
editing: Equal. Lucina Q. Uddin: Conceptualization: Equal; Visualization: Equal; Writing –
original draft: Supporting; Writing – review & editing: Equal.
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