Introduction
India is a culturally and linguistically diverse country with 28 states and 8 union
territories, recording a total of 121 identifiable languages of which 22 are official.[1] Often, individuals born and brought up in urban India are exposed to at least 2
or 3 different languages[2]—their native language, English, and/or another language spoken in the larger community.
More recently, there has been a rise in the preference for English as the language
of formal education and employment, making it an integral part of the country's linguistic
repertoire. Though not a native language, English is now widely understood in most
parts of urban India, making it the second most spoken language.[1] English is now used in high-level business/industrial sectors that involve the global
community, in creative and academic publications, and in communication between literate
individuals, making it the “language of the elite.”[3] Speaking fluent English is thought to increase job opportunities and provide for
better hourly wages. Individuals speaking fluent English earn an average of 34% more
than those who do not.[4] Hence, current-generation parents, particularly those living in metropolitan cities,
emphasize that their child attend English medium schools and learn to speak, read,
and write English fluently. That said, a similar emphasis is made toward children
learning their native language(s). Unique to the Indian scenario is the possibility
of encountering more than one native language within the same family.[1] Additionally, these native languages may be very different from what the neighbors
and/or individuals in the community speak (see [Fig. 1] for description of native and community language). Hence, children growing up in
families with multiple language exposure are likely to be naturally bi/multilingual
themselves.
Fig. 1 Terminologies associated with language environment as defined for the purpose of
this study. *It is possible for one individual to have more than one native language(s).
An individual who can comprehend or speak two languages is considered a bilingual.[5] Similarly, an individual who can comprehend or speak in three or more languages
is considered a multilingual. Studies have demonstrated that infants begin to process
two languages as early as 11 months of age.[6]
[7] Research has shown that exposing an infant to two or more languages early on does
not cause confusion, rather leads to better language learning.[8] Bilinguals follow a similar course of language development in each language as monolinguals.[5] Additionally, bi/multilinguals when compared with monolinguals have an advantage
in terms of better literacy,[8] academic achievements,[8] social flexibility,[9] executive functions,[8]
[9]
[10]
[11]
[12]
[13] and better protection against cognitive decline with age.[8]
[10]
[12]
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by challenges
in social communication and presence of restricted repetitive patterns of behavior.[14] Although the current prevalence of ASD in the USA is reported at 1.85%[15] in children 8 years of age, the global prevalence is projected at 0.62%,[16] and in India it is roughly between 0.23 and 1.4% in children between 0 and 18 years
of age.[17]
[18] Individuals with ASD often have difficulty in developing both verbal (spoken output)
and nonverbal language skills (e.g., use of gestures) to communicate their needs and
understand what others say. About 25 to 30% of these children either fail to develop
functional language or are minimally verbal.[19] These children therefore require speech and language intervention to help develop
their language and communication skills.
Studies (largely case series, parental interviews, surveys, and small-sample intervention)
have reported that bilingual children with ASD develop language similar to their monolingual
nonverbal IQ-matched ASD peers.[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27] Yet, we see professionals (family physicians, pediatricians, teachers, psychologists,
and even speech-language pathologists) often recommend the use of monolingual approach
for bi/multilingual families of children with ASD.[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35] Hence, there is an evident mismatch in what current evidence shows and what is practiced.
As rightly pointed out by Lim et al,[30] no overt reason is discussed in support of a monolingual approach and the decision
of language selection for intervention seems to be based on assumptions and not on
concrete data. Further, it is important to note that available literature around bi/multilingual
exposure for children with ASD is largely based on bilinguals rather than multilinguals.
Additionally, these studies were conducted in countries with English as the primary
language for majority of the population. Not only is there limited evidence around
guidelines to choose language(s) for intervention in a bi/multilingual environment,
but also there is a paucity of evidence for choosing a bi/multilingual approach for
children with ASD in socioculturally and linguistically diverse regions. One cannot
underestimate the complexities that arise during the decision-making process about
choice of language(s) for intervention in children with ASD growing up in naturally
bi/multilingual environments.
In this paper we have first presented a brief overview of existing studies that discuss
various factors that could contribute to the decision-making process while selecting
language(s) for intervention for toddlers and preschool children with ASD who have
bi/multilingual exposure. We have presented these factors under three broad areas.
Next, we have presented four case vignettes to highlight (1) how these factors influence
the decision-making process, and (2) complexities involved in this decision-making
process in a naturally bi/multilingual country like India. We believe that by providing
case vignettes, readers may (1) better understand difficulties faced by professionals
and families when choosing languages for intervention in a naturally multicultural
and multilingual environment, (2) appreciate the change in perspectives with advances
in literature over the past few years, and (3) understand the gaps that persist in
this broad area of autism and multilingualism, both in clinical and research domains.
We also hope that the case vignettes will help readers relate to their own experiences.
Factors Contributing to the Decision-Making Process for Selection of Language(s) for
Intervention
In this section, we have grouped findings from literature on factors contributing
to the decision-making process for selection of language(s) for intervention under
three broad categories: (1) language environment of the child, (2) parent/caregivers'
perspectives regarding bi/multilingual exposure, and (3) medium of education and availability
of intervention services.
Language Environment of the Child
Language environment for the purpose of this paper is defined as the quantity and
quality of language(s) the child is exposed to in various settings, for example, home,
intervention center, school, and community. Language environment can constitute both
native and nonnative languages (see [Fig. 1] for description of terminologies). Research does not indicate significant negative
effect of bi/multilingual exposure on language development for children with ASD.[20]
[21]
[22]
[28]
[36]
[37] However, family interview reports indicate that parents have often received professional
advice to follow a monolingual approach. Often, families chose the nonnative language
(medium of instruction at school/intervention) over their native language. Studies
show that the family's nonnative language proficiency may not be as good as their
native language[33]
[34]
[35] and their competency in the nonnative language may be limited to functional use
only, that is, daily transactional routines and social interactions at workplaces.
Hence, this limits the variety of vocabulary and morpho-syntactic models (quality
of exposure) their child recieves.[33]
[38]
For instance, Yu[33] conducted a case study on a bilingual Chinese-English 6-year-old child with ASD
residing in an English-speaking country. The family was advised a monolingual approach
and chose to speak to the child in the community language (i.e., English). However,
not all members of the family were as proficient in English as in Chinese (sic), and 95% of all utterances between family members were in Chinese (indirect language
stimulation). The study also described how when Chinese was translated to English,
the translations were sometimes irrelevant to the context, further reducing the quantity
and quality of language stimulation the child received in their home environment.
Hence, employing a monolingual approach (nonnative language, i.e., English) in a bi/multilingual
environment could have a detrimental effect on both the child's learning and the family–child
communication.[28]
[39]
Parent/Caregivers' Perspectives Regarding Bi/Multilingual Exposure
Parents form an important part of the decision-making process around language environment
and choice of language for intervention. Parents of children with ASD have expressed
greater concern regarding bilingualism than parents of typically developing children,
often worrying that multiple languages may confuse their child and lead to a further
delay in language development.[30]
[33]
[35]
[40] Other concerns include lack of intervention services in their native language, their
own limited proficiency to communicate in other languages (e.g., community language),
and conflicting advice received from professionals.[21]
[30]
[35]
[37]
[41]
Hampton et al[40] conducted a semi-structured interview on perceptions of parents on bilingualism
in children with ASD and typically developing children residing in English-speaking
countries. All parents included in the study had high proficiency in English. These
parents expressed a need for intervention in the community language (English) to support
academic progress and social inclusion. Whereas, in another study, parents with lower
language proficiency in nonnative language, reported increased stress and/or anxiety
because of their inability to provide adequate language stimulation.[34] Use of monolingual (nonnative/community language) approach was reported to have
adverse effects such as isolation of the child at home and among extended family who
predominantly conversed with each other in their native language. This negatively
impacted family dynamics by inducing feelings of frustration on their child being
unable to converse with elders in the family, combined with the guilt of foregoing
their heritage (native) language.[33]
Previous literature has in fact supported a bilingual environment for better social
participation in children with ASD.[24]
[33] Researchers have suggested that providing a bilingual environment (native and nonnative
languages) for children with ASD would enhance family interaction and maintain familial
culture and heritage. This would allow them to tackle communicative demands in the
community while retaining use of their native language with the family.[33] Thus, it is important to address parents' concern regarding bi/multilingual exposure,
empower them with correct information, and consider their preferences wherever feasible
while selecting language(s) for intervention.
Medium of Education and Availability of Intervention Services
Studies show that parents of children with ASD indicated preference to use English
over their native language for formal education. They believed that formal education
in English would lead to better academic skills, job opportunities, and a more successful
life.[33]
[34]
[35] Additionally, lack of speech-language therapy and special education services in
their native language has increased parents' preference for English over their native
language.[32]
[35]
[41] Lim et al[31] reported less than 10% of children with ASD and related developmental disorders
received formal education in their native language. However, research has shown similar
literacy rates in children with ASD irrespective of the language of instruction.[31]
[42] Medina and Salamon[42] suggested that language exposure at home prior to enrollment in school lays the
foundation to acquire academic skills, regardless of the language used at home. Hence,
the richness of the language environment is crucial to language development as opposed
to which language(s) the child is exposed to.[20] Another important aspect to consider is the influence of cultural differences on
intervention services. Culturally incongruent intervention plans may be ineffective
or fail to address specific needs of the family. A bilingual approach may help the
interventionist and parent communicate better, thereby providing the best possible
care for the child.[43]
The above-mentioned factors are the three most commonly recurring factors reported
in literature that influence the decision-making process to select languages(s) for
intervention for young children with ASD. However, there are several other factors
that may contribute to this language selection process that are not yet explored sufficiently—for
instance, differences in socioeconomic status, nature of occupation of primary caregivers,
family dynamics, policies, and/or special services available, to state a few. The
factors influencing language-decision are often highly dependent on sociocultural
contexts. There is very limited literature on children with ASD growing up in naturally
bi/multilingual countries like India. Hence, it is not surprising that professionals
often face a dilemma while selecting language(s) for intervention for children with
ASD growing up in natural bi/multilingual environments. A better understanding of
language selection across various scenarios in a naturally bi/multilingual context
is important to make informed decisions.
Case Reports
In this section, we have presented four case vignettes of children with ASD from mono/bi/multilingual
backgrounds. Decisions regarding choice of language(s) for intervention were made
prior to the conception of this paper. We have thereafter critically evaluated these
decisions based on the three factors reviewed in the preceding sections, that is,
(1) language environment of the child, (2) parent/caregivers' perspectives regarding
bi/multilingual exposure, and (3) medium of education and availability of intervention
services. Through this section, we aim to demonstrate the complexity and challenges
involved in the decision-making process of choosing language(s) for intervention in
mono/bi/multilingual children with ASD.
Four children aged 29 to 48 months (3 males) were seen between 2013 and 2017, at a
tertiary care hospital (National Institute of Mental Health and Neurosciences [NIMAHNS]).
Behavioral and diagnostic assessments for all children were performed by a multidisciplinary
team that comprised of a child and adolescent psychiatrist, clinical psychologist,
occupational therapist, and speech-language pathologist. A diagnosis of ASD was made
based on clinical best estimate using DSM-5—Diagnostic and Statistical Manual-Fifth Edition. Autism severity was assessed using the childhood autism rating scale (CARS)[44] and/or Indian scale for assessment of autism (ISAA)[45] ([Table 1]). A team of speech-language pathologists (two undergraduate interns in their final
year of a 4-year degree in speech-language pathology and audiology and one speech-language
pathologist with 10 years of experience) conducted a detailed speech-language assessment
based on parent report and direct observation through play. The team of speech-language
pathologists that conducted assessments was multilingual. At least one speech-language
pathologist was fluent in each of the languages the families spoke. Although children
were seen at one time point only (i.e., they were not seen for a follow-up), speech-language
assessments were conducted over 2-hour sessions across 3 to 4 consecutive days. All
four children were evaluated on the Communication DEALL Developmental Checklist (CDDC),[46] a criterion referenced parent report measure. The checklist is administered on children
from birth to 6 years and assesses the child's development across eight domains (gross
motor, fine motor, activities of daily living, receptive and expressive language,
cognition, social, and emotional). Following a detailed assessment, the speech-language
pathologist team designed a home-based intervention program and helped make the decision
of language(s) to be used for intervention. This decision was based on input from
parents and other professionals whenever applicable. Appropriate referrals to intervention
centers at their hometowns were made. Since these children were neither a part of
a formal study that looked at mono/bi/multilingual development nor a part of an intervention
study, no follow-up data was available.
Table 1
Summary of case vignettes described
|
Child 1, SS
|
Child 2, AA
|
Child 3, SD
|
Child 4, PG
|
|
Age/Gender
|
29 months/Male
|
40 months/Male
|
48 months/Male
|
38 months/Female
|
|
Socioeconomic status
|
Lower-middle
|
Upper-middle
|
Upper-middle
|
Upper-middle
|
|
Languages used during assessment
|
Kannada
|
Hindi, English
|
Hindi, English, Tamil
|
Bengali, Hindi, English, Kannada, Malayalam
|
|
Native language(s)
|
Kannada
|
Hindi
|
Hindi, Bhojpuri
|
Malayalam, Bengali
|
|
Nonnative language(s) exposed to
|
–
|
English
|
Tamil, English
|
Hindi, English, Kannada
|
|
Language(s) parents use to communicate with each other
|
Kannada
|
Hindi
|
Hindi, English
|
English, Hindi (English > Hindi)
|
|
Language exposure at home
|
Parents
|
Kannada
|
Hindi, English
|
Hindi, English
|
English, Hindi
|
|
Grandparents
|
Kannada
|
Hindi
|
NA
|
Bengali, Hindi
(Bengali > Hindi)
|
|
Nanny
|
NA
|
Hindi
|
Tamil
|
Kannada, Hindi (Kannada > Hindi)
|
|
Estimated daily interaction at home
(quantitative[a])
|
Parents (predominantly mother)
|
60%
|
50%
|
30%
|
30%
|
|
Grandparents
|
40%
|
35%
|
NA
|
15%
|
|
Nanny
|
NA
|
15%
|
70%
|
50%
|
|
Total number of languages exposed to
|
1
|
2
|
3
|
5
|
|
Medium of instruction at school
|
Kannada
|
English
|
English, Tamil
|
English
|
|
Medium of instruction at intervention services (SLT, ABA, Special education)
|
Not enrolled
|
English
|
Not enrolled
|
Not enrolled
|
|
Perspectives on mono/bi/multi-language approach
|
Parents
|
Bilingual (Kannada, English)
|
Bilingual (Hindi, English)
|
Bilingual (Hindi, English) or monolingual (English)
|
Multilingual (English, Kannada, Bengali)
|
|
Other professionals[b]
|
Monolingual (Kannada)
|
Monolingual (English)
|
Monolingual (Hindi)
|
Monolingual (Hindi)
|
|
SLP's decision at time of assessment
|
Monolingual (Kannada)
|
Bilingual
(Hindi, English)
|
Monolingual
(Hindi)
|
Bilingual
(Hindi, English)
|
|
Alternate recommendation by authors (if any)
|
–
|
–
|
Multilingual (Hindi, Tamil, English)
|
Multilingual (English, Kannada, Bengali)
|
Abbreviations: ABA, applied behavioral analysis; ASD, autism spectrum disorder; ADHD,
attention deficit hyperactivity disorder; ID, intellectual disability; SLP's, speech-language
pathologist's; SLT, speech and language therapy; NA, not applicable.
a Quantity indicated as estimated average daily percent (%) based on parental report
(no standardized measures used).
b Includes child and adolescent psychiatrists, psychologists, and pediatricians.
All four children were predominantly nonverbal, demonstrating challenges in early
social communication skills (e.g., joint attention, eye contact, orientation to name,
imitation, gesture use, sharing of interests, emotions, or affect). They had a primary
diagnosis of mild to moderate ASD with varying comorbidities. None of the children
had siblings. Each case vignette includes (1) descriptive details highlighting the
mono/bi/multilingual environment, (2) the decision taken by the team of speech-language
pathologists at the time of assessment, and (3) a discussion about decisions previously
made (i.e., at the time of assessment) regarding choice of language(s) for intervention
based on the three factors reviewed in the above section.
Child 1
SS, 29-month-old male child diagnosed with ASD, lived with his parents and paternal
grandparents in a semi-urban region of Karnataka, a state in southern India. The child
was diagnosed with mild to moderate ASD based on inputs from a multidisciplinary team.
The family's native language and the language spoken in the community they lived in
was Kannada. The child was enrolled in a Kannada medium playschool. The child's receptive
and expressive language measured on the CDDC was between 6 and 12 months (see [Fig. 2]). He used unconventional gestures to convey his needs (pulled parents near objects
of his interest and used parents' hand to point to something). Parents were in a transferable
state government job and regularly relocated to several rural regions within the state
where the community language remained the same (i.e., Kannada). Parents were most
comfortable using Kannada and were not proficient in English (i.e., their English
use was limited to exchanges like “hello” or “thank you” or included borrowed words
like “market,” “ticket,” “passbook”). However, the parents wanted a bilingual approach
(Kannada and English) with intervention predominantly in English. They wanted to enroll
their child in an English medium school with the hope of giving him better opportunities
in the future.
Fig. 2 Receptive and expressive language scores on Communication DEALL Developmental Checklist.
CA, chronological age; EL, expressive language; RL, receptive language.
In this case, the child's family was predominantly monolingual (Kannada), residing
in a community where Kannada was the language of communication, and the child was
enrolled in a Kannada medium playschool. Parents expressed a preference toward English
for intervention. However, all professionals, including the speech-language pathologist,
recommended a monolingual approach (Kannada) for intervention. Reasons for this recommendation
included: (1) no one in the family was proficient in English, and, (2) parents were
going to be transferred to rural regions where (a) speaking in English with the community
was most unlikely, and (b) medium of education was more readily available in the community
language (Kannada).
Decision at time of assessment: The family was advised to use a monolingual approach in the native language (Kannada)
for intervention.
Discussion: Based on the first factor reviewed, that is, language environment of the child, choosing
a monolingual approach (native language Kannada) for intervention seemed appropriate
as the child was growing up in a naturally monolingual environment. The family was
going to be transferred to rural regions where community language would remain Kannada.
Here, in contrast to the urban regions of India (1) there is little to no use of English
in natural conversational settings, and (2) English is often not spoken in schools,
especially in the lower grades, even though the school may be called “English medium.”
Additionally, since the parents and grandparents were not proficient in English, SS
would have received little to no natural learning opportunities in the nonnative language
(English). This would have compromised the quantity and quality of language exposure
provided to the child, similar to the findings reported by Yu.[35] Based on the third factor, intervention services were more readily available in
the child's native language (Kannada). Moreover, language intervention studies have
reported positive effects of intervention in the native language such as increased
joint attention and play behavior,[47]
[48]
[49] higher response accuracy, and reduced occurrence of challenging behaviors.[50]
Lastly, considering the second factor of parents' perspective, the decision taken
by the speech-language pathologist for choice of language intervention was not in
favor of the parents' choice (English as the language of intervention). This is understandable
given the challenges involved in providing adequate quantity and quality of exposure
in English, that is, in terms of models the child receives to learn new vocabulary.
Further, introducing English as the language of intervention would not have contributed
to increasing the child's opportunities for communication/language learning or integrating
the child into the community at this point of time. It is pertinent to note that the
decision for bilingualism supported in previous literature has mostly been for immigrant
families where the community language has not been the same as the native language.
In contrast, the community language in this scenario is the same as the native language.
However, the decision about choice of language for intervention, that is, Kannada,
does not indicate that the child's exposure to English from the environment must be
restricted in any way. Neither does this suggest that he cannot be enrolled into an
English medium school. It is important to recognize that adopting a monolingual approach
for intervention does not imply that a child with ASD cannot learn more than one language.
A bilingual approach for intervention (Kannada and English) can always be introduced
when the child has adequate natural language learning opportunities in English and
when there is availability of services in both languages. Taken together, a monolingual
approach for intervention seemed to be a suitable option at the time of assessment.
Child 2
AA, 40-month-old male child, was diagnosed with mild to moderate ASD (CARS: 32.5)
and was considered at risk for attention deficit hyperactivity disorder. AA lived
with his parents and paternal grandparents in a metropolitan city in North India.
Hindi served as both native and community language. The child was also exposed to
English at playschool. The child's receptive language was 24 to 30 months and expressive
language was 18 to 24 months as measured on CDDC ([Fig. 2]). Based on parental report, language comprehension was similar in Hindi and English.
His expressive vocabulary largely consisted of single English words (e.g., common
nouns). Parents had decided to enroll their child into an English medium school. Speech-language
intervention and behavioral therapy had been initiated in English. Parents stated
that they were temporarily moving to the USA (6 months) for work and believed intervention
in English would enable their child better access to intervention services and opportunities
there. At the time of assessment, the child spent most of his time with his grandparents
and nanny who spoke their native language (Hindi). When seeking advice from the speech-language
pathologist, parents voiced their concern regarding language selection for intervention
as other professionals recommended a monolingual approach in English.
The speech-language pathologist recommended retaining use of native language, Hindi,
for intervention since the family predominantly spoke Hindi at home. Nonnative language
(English) was also encouraged since (1) both parents were fluent in English, (2) the
child was enrolled in an English medium school where English was the predominant language,
(3) intervention services were available in Hindi and English, and (4) the family
was due to relocate to the USA for 6 months (community language and availability of
services—English). Hence, a bilingual approach (Hindi–English) for language intervention
was adopted. Here, the challenge was to convince other professionals that a bilingual
approach was the better choice.
Decision at time of assessment: Speech-language pathologist advised the family to use a bilingual approach for intervention
(Hindi and English).
Discussion: Based on the first factor, that is, language environment, retaining the native language
during intervention sessions was appropriate since it would enable transfer of skills
introduced in the intervention sessions to the home setting. This would also promote
a rich language environment at home.[34]
[35] Continuing intervention in English alongside Hindi was also appropriate since (1)
parents were proficient in English, (2) child was already enrolled in an English medium
school, and (3) child was already receiving speech-language intervention in English.
As stated previously, literature indicates that there seems to be no significant negative
effect of bi/multilingual exposure on language development for children with ASD.[20]
[21]
[22]
[28]
[36]
[37] The second (parent/caregivers' perspectives regarding bi/multilingual exposure)
and third (availability of services in both native and nonnative languages) factors
were also taken into consideration, where adequate exposure to both Hindi and English
was possible. Additionally, the family was relocating to a country where English was
the community language. Although parents of both child SS (case 1) and this child
(case 2—AA) were keen on English as a language for intervention, including English
for this child was an easier decision to make. Availability of services and English
proficiency of family members aided this decision-making process. Hence, we support
the decision that was made by the speech-language pathologists' team in choosing a
bilingual approach for intervention.
Child 3
SD, 48-month-old male child, was diagnosed with mild to moderate ASD (CARS: 32.5;
ISAA: 94) and mild intellectual disability (ID). This child lived with his parents
and they were originally from North India. Hindi and Bhojpuri were their native languages.
They spoke Hindi more than Bhojpuri. Both parents were central government employees
with transferrable jobs. The father's work brought the family to a small town in southern
India where the community language was Tamil. Parents occasionally used English alongside
the native language (Hindi) when communicating with each other and the child. The
child was looked after by a nanny who spoke the community language (Tamil). The child
was also exposed to Tamil and English at playschool (Tamil > English). The parents,
on the other hand, neither understood nor spoke Tamil. They reported difficulty in
communicating with child's Tamil-speaking nanny. The parents wished for intervention
services to be provided in Hindi and English: Hindi, as this was the language the
family was most comfortable in and they wanted their child to speak their native language;
and English, as they felt this would help their child in academics.
The child's receptive language on CDDC was 24 to 30 months and expressive language
was 12 to 18 months ([Fig. 2]). Based on observation during assessment, free play session, and parental report,
the child seemed to have similar comprehension in Hindi and Tamil. Other professionals
suggested parents use a monolingual approach (Hindi). The parents were concerned that
if they chose a monolingual approach (Hindi), the child might miss out on education
(English).
The speech-language pathologist initially advised the family to opt for a monolingual
approach with native language (Hindi) as (1) Hindi was the predominant language spoken
at home, (2) the child had very little exposure to English, (3) parents could neither
understand nor speak Tamil, and (4) the child's community language was likely to change
every 3 years (sometimes shorter), depending on the parents' transfers. However, they
expressed difficulty in finding intervention services for their child in Hindi. Since
parents were keen to commence intervention immediately, the speech-language pathologist
suggested they opt for parent-mediated intervention. Parents were full-time employees.
They expressed inability to find time to engage in an intensive parent-mediated intervention.
The mother also voiced her difficulties in coping with moving to the new city and
expressed need for more support from family and/or friends. Next, the treating team
asked if the parents were willing to explore provisions such as childcare leave and
preferential transfer (available for central government employees). Childcare leave
would give the mother sometime for herself, which she felt she needed. It would also
allow the parents more time to commence parent-mediated intervention. Preferential
transfer to the northern regions of India would allow the family to readily find intervention
services in Hindi and receive the community support they wished for. The parents readily
agreed to explore this option.
Finally, upon discussion with the family, the mother decided to opt for childcare
leave and temporarily move back to their hometown (community and native language—Hindi).
The father indicated that he would enquire regarding preferential transfer and soon
join the family. Considering the family-centered culture of India, this arrangement
would (1) provide a language rich environment for the child, (2) allow immediate commencement
of intervention for the child in a language the family was comfortable with, that
is, Hindi, and (3) more importantly provide a supportive environment for the family,
especially the mother who felt the need for additional support. The treating team
suggested that the parents could request for a transfer closer to their hometown and
subsequently opt for transfers within north of India (community language Hindi). This
arrangement would ensure that the family remained together as a unit and received
continued support from the community—an aspect that they missed in their area of residence.
Taking all these factors into account, the speech-language pathologist suggested a
monolingual approach (Hindi) for intervention. However, the parents insisted on the
child continuing to learn English since they believed learning English was the way
forward to access good-quality education. As the parents were relatively comfortable
conversing in English and some intervention services were available in English, a
bilingual approach (Hindi and English) was agreed upon.
Decision at time of assessment: A bilingual approach (Hindi and English) was chosen for intervention.
Discussion: Considering the second factor, that is, parents' perspective, SD's parents indicated
ease and comfort in communicating in the native language (Hindi). They, like other
families, also believed that exposing the child to English would lead to better academic
and employment opportunities in the future. Hence, based on parent/caregivers' perspectives,
English and Hindi seemed to be a good choice for intervention for this child. However,
if we consider the first and third factors, that is, language environment that the
child was exposed to, and availability of services at the time of assessment, a multilingual
approach with Hindi, English, and Tamil may have been a better choice.
We recognize that the speech-language pathologists did not recommend Tamil as the
language for intervention as this community language would change in a few months.
However, it is important to ensure that the family does not restrict the child's exposure
to the community language in their place of residence. In addition, we recognize that
the treating team provided information regarding alternate options available such
as parent-mediated intervention, childcare leave, and requesting for a special transfer
to ensure what was best for both the child and the family. This is a very child/family-specific
recommendation and worked for this family since they expressed that they felt unsupported
in their current place of residence. However, though it is the responsibility of a
professional to provide a range of alternate options, including informing families
about different provisions and/or benefits available to them, one must be careful
not to imply that having a child with ASD requires the family to make drastic changes
in their lives (e.g., taking a break from work, relocating). If the message is unclear,
then it can be stigmatizing or even harmful. Professionals must also be careful not
to make recommendations, but simply provide relevant information and leave it up to
the family to decide what would work best for them.
Further, it is important to note that not all families have the provision for preferential
transfer. If this family did not prefer/have an opportunity to move back to their
hometown, and all other factors remained, a multilingual approach may have been the
most practical option (Hindi, English, and Tamil). The parents could comfortably provide
natural language learning opportunities in Hindi and English. The nanny could continue
to use the language she was most comfortable with, that is, Tamil. Intervention could
be provided in English with education in Tamil and English. This would also have facilitated
communication with the child's peers. Such a multilingual approach would have promoted
an overall balanced quantity and quality of exposure in all three languages.
Child 4
PG, a 38-month-old female child diagnosed with mild to moderate ASD (CARS: 32; ISAA:
97) and mild ID, lived with her parents and paternal grandparents in South India where
Kannada was the community language. PG's mother was from Kerala, another state in
South India. Her native language was Malayalam. She was also fluent in English. She
had studied Hindi in school as a second language. She occasionally communicated in
Hindi with her husband and in some social contexts. PG's father was from West Bengal,
a state in eastern India. Bengali was his native language. He was also fluent in Hindi
and English. Both parents had developed conversational proficiency in the community
language, Kannada. PG's paternal grandparents predominantly spoke Bengali with little
proficiency in Hindi and almost little to no proficiency in Kannada. The child spent
half her day with a Kannada-speaking nanny (very little proficiency in Hindi and did
not comprehend or speak Bengali). She spent the rest of her time with her mother and
grandparents. Grandparents were dependent on the family as they were not in good health
and required financial assistance. They did not share a cordial relationship with
PG's mother. They found it difficult to adjust to each other's lifestyles. The grandparents
were also unable to communicate with PG's nanny (Kannada speaking) who took care of
their needs. The nanny had become an integral part of the household as she was with
the family since PG's birth. However, with the complex family situation, the nanny
had indicated that she wished to leave her job. The child was enrolled in an English
medium playschool. Thus, the child was exposed to five different languages at home
and school, that is, Kannada > English > Hindi > Bengali > Malayalam ([Fig. 3]). The family dynamics did not seem to provide a supportive language learning environment
at home for the child.
Fig. 3 Flowchart depicting language environment of child 4. Dotted box (—-) represents members
living with the child.
Child's receptive and expressive language on the CDDC was 6 to 12 months ([Fig. 2]). It was hard to ascertain which language the child comprehended the most and other
professionals had advised the family to use a monolingual approach (Hindi). However,
parents were mainly concerned about the child's education and were keen on receiving
intervention in English. They also expressed that the child would continue to be exposed
to Kannada through the nanny as long as they could retain her, and Bengali through
the grandparents. Considering the complex family dynamics, they were referred to the
family counseling unit for further support in making the home environment a comfortable
place for all. The family was not in a position to take the child for regular center-based
intervention services. Home-based, parent-mediated intervention was the only option
for the child and family. Hence, the speech-language pathologist spent many sessions
trying to understand who the most suitable family member would be to serve as the
primary caregiver/parent therapist. The family decided that the mother would take
on this role.
Based on multiple language exposure and family dynamics, the team suggested that (1)
the family restrict themselves to a bilingual approach (Hindi and English) at home,
(2) for the parent-mediated intervention, the family could employ another nanny from
the father's hometown (Hindi and Bengali speaking) who could assist the grandparents
when communicating with the child in Hindi and improve the family dynamics, and (3)
the child could continue playschool in English.
Decision at time of assessment: Although other professionals suggested a monolingual approach, the speech-language
pathologist team finally recommended a bilingual approach (Hindi and English).
Discussion: It is interesting to note that although all professionals, including the speech-language
pathologist, recommended Hindi, none of the child's primary caregivers had native-like
proficiency in Hindi. Based on availability of services, if the parents had sought
direct intervention choosing common languages (Hindi and English) spoken between the
parent and the therapist (though less proficient than their respective native languages),
it may have been a viable option. However, as this family was leaning toward a parent-mediated
intervention approach, this may not have been the best decision. Based on the first
factor reviewed, language environment, choosing languages with limited quality (Hindi)
or quantity (Malayalam and Hindi) of exposure could have restricted the family's communication
and variety of linguistic models the child received.[40]
[51] Although there is limited literature for this complex scenario, an alternate decision
could have been to explore a multilingual approach with English, Kannada, and Bengali
as languages of choice: English, as both parents were fluent in English and language
of formal education was English; Kannada, since nannies in the region spoke the community
language (Kannada); and Bengali, as the grandparents, who spent a considerable amount
of time with the child, were proficient only in this language. In such complex language
environments, devising a method to measure the percentage exposure of each language
to the child would not only help select languages for intervention, but also help
facilitate balanced language stimulation across languages. As reflected in this case,
the second factor, parent/caregivers' perspectives for choice of language(s) for intervention,
was difficult to honor since each family member wanted a different combination of
languages. Clearly, making this decision was not straightforward for the team of speech-language
pathologists at the time of assessment. It continues to be hard to critically evaluate
their decision since evidence on multilingual approach in intervention is limited.
Summary
Children with ASD, who grow up in culturally and linguistically diverse countries
like India, are exposed to different languages to varying extents. Previous research
on bi/multilingualism and ASD has indicated that both monolingual and bilingual children
with ASD follow a similar pattern of language acquisition.[21]
[22]
[24]
[36]
[51] Upon reviewing literature, we observed this to be true irrespective of the varying
linguistic characteristics (phonotactic rules, sentence structure, and so on) across
different languages studied (e.g., English–Spanish,[26] English–Mandarin,[24]
[33] English–Hindi,[23] English–Urdu[52]). In spite of recent evidence, reports have indicated that professionals still advise
a monolingual approach for intervention for children with ASD.[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35] We noticed a similar trend in our clinical practice too, in India. Most professionals
(family physicians, pediatricians, teachers, psychologists, and even speech-language
pathologists) seemed to continue to recommend a monolingual approach, until the child
starts to speak in sentences. This is advised even for families that naturally speak
two or more languages. Here, convincing other professionals to adopt a bi/multilingual
approach can be quite challenging. This could be due to their lack of awareness of
existing literature or their adherence to old practice (advice being handed down by
clinicians over many years). More often than not, other professionals make these decisions
without consulting with a speech-language pathologist.
In this article, we first reviewed recent studies that address the issue of language
selection for intervention in toddlers and preschoolers with ASD, growing up in bi/multilingual
environments. Three commonly discussed factors influencing the decision-making process
for selection of language(s) were (1) language environment of the child, (2) parent/caregivers'
perspectives regarding bi/multilingual exposure, and (3) medium of education and availability
of intervention services. Next, we presented four case vignettes to highlight the
challenges faced by speech-language pathologists in making a decision around choosing
mono/bi/multilingual approaches in a naturally bi/multilingual country like India.
Lastly, we critically evaluated the decisions made by the speech-language pathologists
for each child, based on the three commonly discussed factors that influenced this
decision in previous studies.
As mentioned before, majority of the existing literature has been conducted on immigrant
families in predominantly English-speaking countries with limited studies in naturally
bi/multilingual countries like India. Lack of studies from these countries is likely
due to methodological constraints such as participant heterogeneity and nonavailability
of outcome measures or assessment tools that comprehensively assess language abilities
in all languages. Furthermore, most of these studies focus on bilingualism rather
than multilingualism. Hence, there is an urgent need for in-depth research exploring
effects of multilingual approach for intervention on language development in young
children with ASD. For instance, would the impact of introducing five languages be
different from introducing three? Would the child's developmental age, severity of
ASD, or presence of comorbidities impact multilingual language development? Would
parental education and socioeconomic status play a role? Development of standardized
tools across languages, in-depth parental interviews, and systematic research investigating
the influence of bi/multilingual approach across participant characteristics are areas
that need to be studied in detail. Stronger study designs with a larger sample and
adequate follow-up data can help gain better insight on the language decision-making
process and help formulate appropriate guidelines for the same.
This article is not without limitations. Data on the children reported in the case
vignettes were not part of a formal study. Instead, they were retrieved from case
records. We cannot rule out potential recall bias as not all information was complete
in case records and the speech-language pathologist team recollected missing information
about the children wherever possible. Formal tests for language assessments were not
administered due to limited availability of standardized tests in native languages.
The scenarios described were mostly from the upper-middle socioeconomic strata (SES),
whereas challenges could be different for children belonging to other SES with varied
parental education and occupation, and access to and affordability of intervention
services. Lastly, since the information discussed in this paper was not collected
as part of a formal study, we do not have follow-up data to critically evaluate the
child's language development across languages. Ideas that emerged from each vignette
cannot be taken as evidence for a bi/multilingual approach due to the inherent limitations
that case studies as a design pose. Instead, findings from the case vignettes must
be used to inform future study designs.
In conclusion, choosing language(s) for intervention in a multilingual context is
especially complex. Presently there are no guidelines or standard procedures that
can be adopted. Several factors must be considered while making these decisions as
it varies from child to child. The key is to involve families and other professionals
in the decision-making process. Parents' concerns regarding exposure to multiple languages
must be addressed through public education materials, screening camps, and/or community
workshops. It is important to collaborate with and sensitize fellow professionals
like pediatricians, child psychiatrists, clinical psychologists, occupational/physical
therapists, and social workers to the existing literature. This can be done through
seminars, workshops, and research presented at conferences/symposia and by encouraging
them to make appropriate referrals to speech-language pathologists for guidance regarding
language decisions. There is an urgent need to create a strong evidence base and develop
an assessment battery that can capture the effect of bi/multilingualism on language
development. Such research can then help formulate guidelines and inform policy development
in this very crucial area that has become the need of the hour.
