Does a Primary Language Impairment Affect Both Languages in a Bilingual Child?

Patient Presentation
A 4-year-old Spanish-English speaking male came to clinic because his preschool teacher was concerned about his language development. His mother said that the teacher said he didn’t talk as much as the other children and seemed more shy. Using a Spanish interpreter, the mother reiterated that they had come to the United States 2 years ago because of work. Her English language skills were quite good, but she wanted a translator to make sure her concerns were understood. The child had been in the preschool for about 4 months and before this the child was taken care of at home where both parents and extended family spoke mainly Spanish. The mother said that she and the teacher had no concerns about his development otherwise. In Spanish he was able to speak 5 or more word sentences and easily tell a story, understand 2-3 step commands, follow directions and could be understood by others. Family members agreed with this assessment. The child would not use English with his family so his mother was not sure how good his English skills were. A Spanish-English teacher aide at the preschool had told the mother that she felt his Spanish was comparable to other children, but that he seemed quieter overall and hadn’t made as many friends yet at school.

The past medical history revealed a previously full-term infant with no prenatal or postnatal complications. He had no significant illnesses and had been fully vaccinated. The family history was negative for any developmental problems. The review of systems was negative.

The pertinent physical exam showed a healthy appearing male with normal vital signs and growth parameters were in the 75-90%. He had a normal neurological and general examination. He initially seemed quiet but then easily engaged with the pediatrician and was able to follow a simple game. His gross motor and fine motor skills were appropriate. He easily counted to 4 in English and named 2 colors in English and 3 in Spanish without hesitancy.

The diagnosis of a healthy child who was learning a second language was made. The pediatrician said that maybe he should be taught a way of asking for help with language in the classroom when he was working with English-speaking teachers and peers. Also having the Spanish-language teacher aide available in the classroom might also help him to be more comfortable and assist with his language acquisition. A designated consistent peer to be his “special friend” for language activities may also help. Additionally, the pediatrician recommended a hearing test which at followup during his well child check 4 months later was normal. The mother said that the teacher was now not concerned as he seemed to be learning and using more English. The mother said he seemed more comfortable at the preschool too.

Internationally, bilingualism is the rule. Even in the US which many have considered the holdout for monolingualism, bilingualism is increasing with more than 18% of people (>5 years) speaking 2 languages and it is expected that by 2030 more than 40% of children will learn English as their second language (L2).

Children learn two or more languages in different contexts. A child may learn two language with parents speaking two different languages at home since birth, may have one language spoken at home and another in the community (such as a daycare setting) since birth, or may learn one at home since birth and a second at a later age when they have wider experiences (going to Kindergarten) with their community or immigrate to another country. There are places where bilingualism is less of an immigrant phenomenon and is an integral part of the community. Examples of stable bilingualism are French-English speaking parts of Canada, or Welsh-English speaking parts of Wales.

Children can successfully use both languages. Just because a child is young does not mean they will be more proficient in the second language (L2). There is data from children who immigrated in the year before school begins and the year afterwards. The older children who immigrated and moved directly into a school setting became more proficient. This is probably because they were older and more proficient in their primary language (L1).

Children use their languages differently depending on the audience (parents, partners, siblings, teacher, community member), and venue (home, school, Internet, work), purpose (asking for directions, explaining school work, telling stories at a family celebration) and their developmental abilities. The dominant language spoken may change across age and learning opportunities but both can be functional.

Children who learn two languages from birth have language acquisition that is comparable or greater than children who acquire only 1 language. But the growth is split between the two languages. A child may seem behind in one or both languages when looking at vocabulary and grammar development, but most children are within range of normal. There is some data that supports children’s skills ‘catching-up” to monolinguistic children by age 9-10 years.

“When both parents are minority language speakers, the children are more likely to sustain bilingual development than when only one is. Some studies also find that parents are more likely to use the minority language with daughters than with sons and that girls are more likely to develop as bilinguals than boys.”

“Language exposure in the context of book reading is particularly supportive of development in [both] language[s], and language exposure via television is not particularly supportive [of language development].”

Adolescent who speak both their home and their community language are more likely to graduate from high school, than peers who speak English only. Minority language use can be supported by continued close family and cultural connections.

Data from children who immigrate to another country have found that school age and adolescents need about 2-3 years to become conversationally fluent in their second language (L2) but it takes about 4-5 years to achieve proficiency conducive to academic achievement. Therefore adolescents who immigrate may not have enough time in the school environment to show their true academic achievement.

Learning Point
Primary language impairments in bilingual children can be difficult to discern. The main issues are to determine if the child has a global developmental issue, a primary language impairment (PLI) or learning disability, or does the child have difficulties learning the L2.

L1 proficiency and cognitive development are the key variables to L2 acquisition. A child who has a PLI, has problems in both languages. A child who has a PLI in their L1 will have problems learning a L2. This does not mean that they cannot be successful but they are less efficient in their learning than their unaffected bilingual peers.

“Poor performance on language tasks, in the face of otherwise typical development, is considered the critical marker of PLI.” There may be other cognitive weaknesses that are not as apparent such as working memory, attention, and information processing speed.

A review of indications for referral to speech therapy can be seen here.

Questions for Further Discussion
1. What services are available in your local community for bilingual education?
2. How are interpretative services best utilized?
3. How do socioeconomic factors affect second language acquisition?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Speech and Language Problems in Children

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Kohnert K. Bilingual children with primary language impairment: issues, evidence and implications for clinical actions. J Commun Disord. 2010 Nov-Dec;43(6):456-73.

Hoff E, Core C. Input and language development in bilingually developing children. Semin Speech Lang. 2013 Nov;34(4):215-26.

Clifford V, Rhodes A, Paxton G.Learning difficulties or learning English difficulties? Additional language acquisition: an update for paediatricians. J Paediatr Child Health. 2014 Mar;50(3):175-81.

Cote LR, Bornstein MH. Productive Vocabulary among Three Groups of Bilingual American Children: Comparison and Prediction. First Lang. 2014 Dec;34(6):467-485.


Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital