Editor's note: This text-based course is a transcript of the webinar, Pediatric Bilingual-Learner Primer for Therapists, presented by Tara Konradi, OTD, OTR/L.
Please also use the handout with this text course to supplement the material.
Learning Outcomes
After this course, participants will be able to:
- Describe foundational patterns of bilingual development and how bilingual environments influence participation, engagement, and functional performance in pediatric clients
- Identify cultural and linguistic factors that impact assessment, goal setting, and intervention planning across pediatric practice settings
- Recognize strategies to reduce bias and support culturally responsive, family-centered care when working with bilingual and multilingual pediatric populations
Introduction
Thank you so much for having me. I am really excited to be here and to share this topic with you because it is something that is very close to home for me — both professionally and personally. I am American, I am married to a multilingual European, and I am bilingual myself in English and Spanish, with conversational French and basic Mandarin. My children are growing up in a multilingual household, so the concepts we are going to be talking about today are something I see every day, not just in my clinical work, but in my own family. I have 18 plus years of pediatric, school-based, telehealth, international, and leadership experience. I earned my Doctorate in Occupational Therapy from Creighton University in 2007 and have lived and practiced in the United States, Europe, and Taiwan. My family also lived in Taiwan for five years, where my older children acquired Mandarin. I currently raise three multilingual children in Barcelona and provide pediatric therapy and consultation through telehealth and international practice through my practice, TaraPedOT. The concepts we are discussing today are not abstract to me. They are part of my daily life, and they are central to the clinical work I do every day.
One quick note on terminology before we start. Throughout the course I will often use the term bilingual. The course name is bilingual, and for the purposes of the course I am sticking with that. However, it does refer to two or more languages, since many of the concepts we will discuss apply across bilingual and multilingual language environments. So wherever I use the term bilingual, please understand that I mean any child navigating two or more languages across their daily life.
So let me walk you through how the course is structured today. We are going to begin with an introduction and framing where we will talk about why bilingual and multilingual learners are a rapidly growing population in pediatric practice and why understanding the context surrounding a child's language environment is essential for accurate clinical interpretation. From there we will move on to bilingual developmental foundations where we will look at some of the common developmental patterns we see in children growing up with more than one language. This includes how language exposure, timing, and environments shape learning trajectories and what typical development looks like. Next, we will connect those ideas to functional implications in pediatric therapy. We will look at how bilingual environments intersect with areas we work in every day, such as movement, regulation, play, executive functioning, and daily routines. After that we will move into case applications. I always find that concepts really come alive when we look at real-world scenarios, so we will walk through a few clinical examples and apply the framework we have been discussing. Then we will move into culturally responsive assessment and intervention, where we will focus on practical ways to interpret performance more accurately and to support bilingual learners and their families in ways that are both clinically sound and culturally responsive. Finally, we will sum things up and revisit key ideas, talk about how those concepts translate to everyday clinical reasoning and goal writing, and I will check in periodically throughout — feel free to engage and reflect as we go.
Now, why does this matter in pediatric practice? There are a few core ideas I want to establish right at the start. Bilingual and multilingual learners are a rapidly growing population in pediatric practice settings. Depending on where you practice, you may already be seeing this. You have children navigating different languages across home, school, and community environments. Second, differences in performance are often interpreted before context is considered. Something looks different and it can quickly get labeled as a delay before we step back and take a look at the bigger picture. Third, language environment, culture, and routines shape participation. Children may participate differently depending on the language being used, the expectations of the setting, and the routines they are familiar with. We are going to deep dive into all of this as we go along. And finally, accurate interpretation begins with a shift in clinical lens. Instead of immediately asking what skill is missing, we start by asking what is the child being asked to do, and in what context?
I want to emphasize that last point because it is the foundation of everything we are building in this course. The shift from asking "what is wrong with this child?" to asking "what is this child being asked to do, and in what context?" is not a small adjustment. It is a fundamental reorientation of our clinical reasoning. It changes how we set up assessments, how we gather history, how we interpret what we observe, and how we write goals. Everything else in this course builds from that one shift.
The framing of this entire course comes down to four commitments. We will be understanding bilingual development through a participation lens — looking at how language experience connects to what children actually do in everyday routines at home, in school, and in therapy. We will be interpreting performance within cultural and linguistic context, thinking about the environments, the expectations in those various environments, and the language demands surrounding that child. We will be developing intentional clinical reasoning frameworks. Even if we are bilingual ourselves or grew up in bilingual households, we do not automatically assess through a bilingual clinical lens. Sometimes clinical reasoning just requires a better framework to help us interpret performance within context. And we will be supporting accurate and culturally responsive decision-making throughout, so that our interpretation of performance reflects the child's actual abilities rather than our assumptions based on monolingual norms and expectations.
Bilingual Environments in Pediatric Practice
What Makes an Environment Bilingual
Bilingual development is always shaped by real people, places, and routines — the environments that the child moves through throughout the day. Each one of those spaces carries its own language patterns, its own communication partners or peers, its own expectations, and its own routines in that language. A child may primarily use one language at home and another language at school, have different language expectations during therapy, and then encounter a mixed language in the community at playgrounds, activities, or stores. An environment becomes bilingual not simply because two languages exist, but because bilingual children are navigating these different environments — different people, different communication expectations, and different routines depending on where they are. Research supports this idea. Rojas and Iglesias (2021) found that differences in language exposure across environments influence children's learning trajectories and the performance we observe. When exposure varies across environments, observed performance may also vary.
When we are working with bilingual children, it is important to pause and ask: where is this child using language, who are they using it with, and under what conditions?
Home Environment
For many bilingual learners, home is where their primary language exposure happens. It is also the setting where routines tend to feel the most familiar and predictable. Language at home is embedded in everyday family routines and interaction styles. We are not just talking about vocabulary here — we are talking about language during real occupations like meals, play, dressing routines, bedtime, and transitions. Language is woven into the fabric of daily family life in the home environment. Because these activities are familiar and meaningful, home is where children usually show their highest level of comfort, regulation, and predictability. This matters enormously for our clinical work because home performance is often the most accurate window into what a child is truly capable of. When caregiver reports tell us a child is doing something well at home that we are not seeing in our sessions, that information is clinically significant — it tells us the skill is there and that what we are observing in therapy reflects the demands of the therapy context, not the limits of the child.
School Environment
School typically brings higher language demands. There are multi-step directions and expectations for verbal participation. Children are navigating group instruction and social expectations. The pace is usually faster and there may be less individualized language support compared to home. Because of all of this, it is not unusual for a child who communicates comfortably at home to appear quieter, slower to respond, or more hesitant in the classroom. It is also important to remember that the academic language of school is different from the conversational language of home. Children may have strong conversational fluency in a language but still struggle with the academic language demands of school instruction — understanding multi-step directions, following complex verbal explanations, or keeping pace with whole-group instruction. That gap between conversational and academic language proficiency is real and can significantly affect how a bilingual child appears in the school setting.
Therapy Environment
The therapy environment is also usually adult-directed and structured, with activities designed around specific therapeutic goals. For many children, the materials, routines, and expectations in therapy may be unfamiliar at first. Language in therapy can also be more structured than in natural environments — we might ask direct questions, provide prompting, or use specific vocabulary related to the task we are working on. Because of this, the child's participation in therapy might look different from their participation in everyday routines. Therapy performance is just one data point — it is not the full picture. That is why we want to gather information across environments: home, school, and community. The difference in performance across settings does not necessarily reflect ability. It reflects a shift in the demands of the environment. I always remind myself of this when I am looking at what I am observing in a session: I am seeing this child perform under the specific conditions of this moment, in this room, with these task demands, in this language. That is valuable information, but it is not the whole picture of who this child is.
Community Environment
In community settings like playgrounds, stores, and activities, there is often mixed language exposure. Children may hear different languages from peers, adults, and the surrounding environment. Some people might share the child's home language, and others might not. The level of support is also variable — sometimes caregivers are nearby and helping with communication, and other times children are expected to navigate interactions more independently with peers or unfamiliar adults. This variability is important to understand. Because community often presents mixed language exposure and variable support, observing or asking about participation in community settings gives us important information about functional communication, social engagement, and adaptability across contexts. A child who navigates community environments with relative ease may have strengths in flexibility and adaptability that are not visible in the more structured demands of school or therapy. Conversely, a child who thrives at home and in therapy may struggle in community settings where the language is less predictable and the support is less consistent. All of that is useful clinical information.
Environment Influences Participation — A Personal Example
I want to share a real-life example from my own home to illustrate how environment shapes language use. My daughter attends a French school, and she does swimming there. When I ask my daughter in English what day she has swimming, she always answers me in French — because that is how she recognizes it, is familiar with it, and knows how to express it. Even though I am speaking to her in English, the information is stored in the language connected to the environment and the concepts there. The word just lives in a different language system in her brain. It is the same child, the same brain, the same competence. What changes is the environment, the communication partner, and the expectations of what language she is expected to be speaking. When we change the environment, the demands change, and participation can change as well.
Foundational Patterns of Bilingual Development
Typical Bilingual Development Is Dynamic
Now we are moving into the foundational patterns of bilingual development — what typical bilingual learning trajectories can look like and how these patterns relate to participation and functional performance.
There are three key ideas to anchor this section. First, development is dynamic. Bilingual development is constantly adapting to a child's exposure and experiences. As children move between environments, languages, and communication partners, their language systems continue adjusting and reorganizing. Second, growth is not linear. We often expect development to follow a smooth upward trajectory, but bilingual learning does not always look that way. Children may move through periods of rapid progress, periods where things seem to plateau, and moments where language use shifts between their languages. Third, variability is expected. A child might suddenly begin using more of one language and less of another, or they may appear very expressive in one setting but quieter in another. That variability does not automatically signal regression or loss of ability. It reflects how bilingual language systems organize themselves based on exposure, experience, and the context.
When we see variability in bilingual learners, it is important to remember that variability is often a typical feature of development, not a red flag.
Simultaneous and Sequential Bilingualism
There are two primary developmental pathways in bilingual development. The first is simultaneous bilingualism — two languages early on. This refers to children who are exposed to two languages from birth or very early in life. In these situations, both languages develop alongside each other. A common example is the one parent, one language approach, in which each caregiver consistently speaks a different language with the child. One parent always speaks English and the other always speaks Spanish, for example. That is what we do in my household. Over time, the child learns that different people communicate in different languages and begins to organize those language systems accordingly. You might also see simultaneous bilingualism in families where multiple languages are naturally used throughout daily routines — parents may speak one language together, grandparents speak another, and the child hears both regularly during everyday activities. In these cases, children are essentially building two language systems at the same time.
In simultaneous bilingualism, children often develop balanced or overlapping skills across both languages because they have consistent exposure to both from the start. The learning process involves parallel acquisition of both languages simultaneously. Key characteristics include steady, concurrent progress in both languages, and children often reach similar milestones to monolingual peers — the total vocabulary size across both languages frequently matches that of monolingual peers when combined. The exposure pattern is continuous and consistent to both languages from the very beginning.
The second pathway is sequential bilingualism — second language later. This refers to children who learn one language first and are then introduced to a second language later. This is most commonly seen when one language is used at home and the child begins attending a preschool or kindergarten where a different language is used. A child might grow up speaking Spanish at home and then begin school in English. We also see sequential bilingualism when families move to a new country and children are suddenly immersed in a new language at school or in the community. In these situations, the child already has an established first language and begins adding the second on top of that existing language. In sequential bilingualism, the second language is learned after the first is already established. The first language is typically stronger at first, while the second language develops gradually as exposure and opportunities to use it increase. Sequential learners often experience more distinct environments for each language — one language primarily at home and another at school. And sequential learners may experience that silent or reduced output phase I described earlier as they orient to the new language.
Rojas and Iglesias (2021) highlight that bilingual development is shaped by how much exposure a child has to each language, when each language is introduced, and the environments in which each language is used. Because these exposure patterns vary so widely, bilingual children naturally follow different developmental trajectories. If two bilingual children look very different in how they use language, that difference may not mean that one child is delayed — it might just reflect differences in their exposure history and language environments. Both simultaneous and sequential bilingualism represent typical patterns of bilingual development. This is an important clinical anchor point: both are normal, both are expected, and both produce children who are doing exactly what bilingual development looks like.
It is also important to understand that language dominance can shift when exposure changes. A child who primarily spoke Spanish at home may begin using much more English after entering an English-speaking classroom. Over time, English might even become the stronger language simply because it is used more frequently. This does not mean that the first language has disappeared — it reflects how bilingual systems adapt to the environments where children are communicating most often. Another very common pattern is what happens when a child grows up speaking one language at home, then begins school in English, and the parents continue speaking the home language to the child but allow the child to respond in English. The interaction becomes one language from the parent and a different language from the child. This is a very common example of how language dominance can shift based on exposure and environment. The child has not lost their home language — but English has become the language they are using more frequently across their day.
Skills Distributed Across Languages
One of the concepts I want to make sure we really anchor before we move on is the idea that skills are often distributed across languages. A bilingual child might know certain words, concepts, and routines in one language but different words and concepts in another. This is not a gap — it is how knowledge is often organized across languages in bilingual development. Skills may be expressed differently across environments, and this organization reflects the contexts where learning happened.
A real-life example from my own household illustrates this clearly. My daughter goes to a French school, and she does swimming there. If I ask my daughter in English what day she has swimming, she always answers me in French — because that is how she recognizes it, is familiar with it, and knows how to express it. The information is stored in the language connected to the environment and the concepts there. The word just lives in a different language system in her brain. This is completely typical. It is the same child, the same brain, the same competence. What changes is the environment, the communication partner, and the expectations of what language she is expected to be using.
Proficiency can also vary by context. A child might sound very fluent in one environment and need more processing time in another, and that is entirely normal and expected in bilingual development. When we observe a child who seems to know something in one context but cannot access that same knowledge in a different setting, the question should not be whether the skill is present — it should be where and how the skill was learned, and whether the current context is one that supports access to it.
Language Dominance Shifts
One more pattern that is important to understand is how language dominance can shift across a bilingual learner's development. Proficiency can and does shift when exposure changes. In simultaneous bilingualism, children often develop balanced or overlapping skills across both languages because exposure is consistent to both from the start. In sequential bilingualism, the first language is usually stronger at first, while the second language develops gradually as exposure and opportunities to use it increase.
But even in families that started with clear patterns — say, Spanish at home and English at school — dominance can shift over time as the child's daily exposure changes. A very common pattern we see is this: a child grows up speaking one language at home and begins school in English. As their exposure to English increases at school, and through extracurriculars, peers, and media, the parents may continue speaking the home language to the child. But if the child understands English well enough that the parents allow the child to respond in English, the interaction becomes one language from the parent and a different language from the child. The child is hearing the home language but speaking English back. This is a very common example of how language dominance can shift based on exposure and environment. It does not mean the child has lost their home language — they are understanding it and using it in the home context. But English has become the language they use more frequently across their day, and so it develops and strengthens accordingly. If there is not a genuine need to use a language in everyday life, children's systems will naturally prune toward the languages they need most. When we see a child who responds in a different language than the one being addressed, that is not a communication breakdown — it is the bilingual system doing exactly what it is designed to do.
The Silent or Reduced Output Phase
Some sequential bilingual learners — children who are introduced to a second language after their first is already developing — go through a period where they produce little verbal output in the new language. This is so common that it has its own name: the silent or reduced output phase. During this phase, children are actively listening and processing. Rather than immediately speaking the new language, the child is comparing, mapping, and organizing the new language onto what they already know. It is going on top of the existing system. Learning is happening internally before it becomes visible through speech. Understanding often develops before spoken expression — a child might demonstrate comprehension by following routines, responding to directions, or participating appropriately, even when they are not using many words. Participation during this phase may be primarily nonverbal. Children can participate through gestures, eye contact, imitation, movement, following routines, and copying what peers are doing in the classroom. All of those behaviors reflect active learning, not an absence of ability. This phase is temporary and expected.
I want to share the fuller personal story I mentioned briefly earlier, because it illustrates this phase in a way that I think will really stay with you. When we moved to Barcelona, my youngest daughter went to a daycare conducted in Catalan, and she decided to not speak the entire year we were there — not one word at school. The teachers were very worried and referred us to early intervention speech therapy services. But the language was there at home. She was communicating with me in English and with my husband in Spanish. We did go through the full evaluation process, and the speech therapist found that there was nothing wrong — she really was going through the silent period. Now that is very close to home for me, and it hit me as an OT in a way I did not expect. Because even I, knowing what I know about bilingual development, was worried. I was questioning myself. And of course, not every quiet child is experiencing a silent period. But it is always important to consider the child's developmental history, where they came from, their exposure patterns, and the environment before drawing conclusions.
I will tell you the rest of that story because it has a beautiful ending. The following year, we put my daughter in French school where her older brothers were enrolled. We were honestly a little worried — here we go again, another new language. But after about a week, I crept into the teacher's room and asked how things were going. The teacher was genuinely shocked. She said, oh, yes, she is fine — she is already saying things in French. How does she know French? And the answer was: she did not know French. But she was finally over that silent period. She was ready to try. Whether it was the change in environment, the familiarity of seeing her brothers in that school, or simply the natural progression of that developmental phase, we do not know for certain. But it was a powerful reminder that when you feel comfortable, when the environment feels safe and predictable, that is when participation expands. That is when language comes out.
When we recognize the silent or reduced output phase as a typical part of sequential bilingual development, we are much less likely to misinterpret limited verbal output as delay or reduced ability. From a therapeutic perspective, what matters most during this phase is not how much a child is speaking, but how the child is participating. And participation, as we have been establishing throughout this course, looks different across contexts — and that is completely expected.
Functional Implications in Pediatric Therapy
Bilingualism Is More Than Language
Up to this point we have been focused on understanding how bilingual development works — exposure patterns, learning trajectories, and the environments where children use language. Now we shift to clinical interpretation — specifically, how these bilingual developmental patterns influence participation and functional performance in the environments where our children live, learn, and receive services.
I want to start with something that sounds obvious but has real clinical weight: bilingualism is more than language. When we talk about it, we are not talking about just vocabulary. We are talking about navigating multiple systems at once. Children navigating bilingual environments are managing multiple languages, different expectations and routines, changing social and cultural rules, and different ways of participating depending on where they are. At home, a child might speak freely and interrupt or talk over family members, and that is accepted and normal in their household. But in the classroom, they are expected to raise their hand, wait to be called on, and respond quickly when prompted. The child is constantly adjusting to different expectations tied to different languages. In some cultures, making direct eye contact with adults is expected and valued. In others, it might be considered disrespectful. Some environments expect quick verbal responses. Others call for quiet observation before speaking. The child is not just switching languages — they are adapting to different social rules, because social rules are often tied to language. Participation reflects all of these shifting demands.
In therapy, we almost never see language by itself. What we actually see is participation. A child might be talking, playing, moving, listening, following directions, and interacting with others all at the same time — a lot of different systems are working together. Kids are not just translating words. They are coordinating many different systems while navigating language. Differences in exposure, familiarity, and cognitive load can influence how children participate across domains such as motor development, sensory processing, executive functioning, play, self-regulation, and daily routines. The domain tells us what we are observing. The environment tells us where it is happening. And the context tells us what the situation is like.
I love thinking about a child's world as overlapping circles — the home, the school, the therapy setting — all intersecting. These are not just different locations. Each circle is a different participation system with its own language, its own social rules, its own expectations for how a child should show up. Children know how things work at home. At school, the environment shifts. In therapy, this adds another layer entirely. Every time a child crosses from one circle into another, they are doing interpretive work. They are reading the room, recalibrating expectations, figuring out who they need to be in this space and what participation looks like here. A word learned at home in one language might appear in another language at school. A routine at home might work differently in the classroom. The child is constantly figuring out how to connect: this word matches that word, this routine matches this routine, these rules match those rules. That mapping is happening in the background every time the child moves between environments. It is a lot of work.
Here is the piece that changes everything clinically: the child has not changed. The system around them has. When we see a child who participates beautifully at home but appears disengaged or slower in therapy, maybe we should not immediately ask what is wrong. Maybe we should ask: what has changed within this dynamic system? What language shifted? What expectations shifted? What familiar cues have disappeared? That question is the beginning of accurate interpretation. Participation differences may reflect the cognitive load of navigating these multiple systems rather than an absence of skill. Culturally responsive practice emphasizes understanding children within their linguistic and environmental contexts rather than interpreting performance in isolation (International Journal of Speech-Language Pathology, 2022). When a skill appears in one setting but not another, we need to consider contextual demands and exposure differences before assuming delay.
For each domain I am about to walk through, I want you to hold this frame: the domain tells us what we are observing, the environment tells us where it is happening, and the context tells us what the situation is like. We are not saying bilingualism causes difficulties in any of these domains. We are recognizing that navigating multiple language expectations and environments can influence how participation looks. That is an important distinction.
Motor Performance
Motor performance is not separate from the cultural and linguistic context in which movement is learned and practiced. Lopez and Tiles (2020) remind us of this directly — motor skill development in bilingual children cannot be separated from the cultural and linguistic contexts in which movement is learned and practiced. What a child carries, how they carry things, how they sit, how they use tools, how they transition between activities — all of it is shaped by what is practiced and valued in their environment, initially and primarily at home. Motor performance may be influenced by cultural movement routines, tool use expectations regarding hands, utensils, and writing tools, postural expectations across environments, and practice opportunities within daily life. Movement is learned within cultural routines, and when we observe motor performance, we are observing the interaction between skill and experience, not just ability alone.
Tool use is a good example of this. In some families and cultural contexts, children eat primarily with their hands, or with utensils that differ from what school expects. In some environments, carrying objects on the head or back is part of daily life. Writing tools and how they are held may differ. The expectations for how a child holds a pencil, manipulates scissors, or manages classroom materials may not match what has been practiced at home, and that mismatch can look like a fine motor difficulty when it is really a difference in exposure and practice. Postural expectations are similar. Some settings expect floor sitting; others expect chairs at desks. A child who has primarily sat on cushions or mats at home may organize their body differently in a classroom chair, and what looks like poor postural control may actually reflect adjustment to a new positioning context. Practice opportunities within daily routines also shape motor skill development. Some children have plenty of opportunities to practice climbing, fine motor tasks, or structured movement experience. Others may have more limited opportunities in one environment, and those skills may appear differently in a new setting.
One pattern that is particularly important to watch for is what happens to motor coordination when language demands increase. When cognitive load rises — when a child is processing instructions in a second language, trying to understand what is being said, what is expected, and how to respond — motor performance can look different because attention is being directed toward the language rather than toward the movement itself. You may notice coordination looks different when language demands increase. That is not a motor impairment. That is the cognitive architecture of bilingual participation at work.
What might motor performance differences look like clinically? We see slower initiation of movements during unfamiliar tasks, where the child may take extra time because they are orienting to the environment and the language before they begin moving. We see hesitation with new tools or materials, because the child is adjusting to tools that are used differently at home versus at school. We see changes in posture or endurance across settings. We see variable coordination depending on language or task demand. And we see strong motor skills in one environment but less consistent performance in another. That variability often reflects adaptation to context, not a motor impairment. Remembering this helps us avoid writing motor goals that are actually addressing a context mismatch rather than an underlying motor need.
Sensory Processing
Sensory responses may be influenced by participation context in several ways. Environmental stimulation differs across settings — different levels of noise, visual input, and social activity can influence how children regulate their attention, behavior, and participation. A child who handles the sensory demands of home beautifully may appear much more dysregulated in a loud, fast-paced classroom — not because their sensory system has changed, but because the environmental demands have. Cultural expectations for regulation also vary. Some environments expect quiet and stillness, while others allow more movement, expressiveness, or flexible, active participation. Children learn what regulated behavior looks like within their own family and cultural context first, and when they arrive in a school or therapy setting with different expectations for how bodies should be managed, there can be a mismatch that looks like a sensory difficulty but actually reflects a difference in expectation.
Language demands during tasks add another layer. When children are working in an unfamiliar or complex language, cognitive resources are being shared between understanding the communication and managing the sensory input around them. Those two demands compete with each other, which can meaningfully influence a child's ability to regulate during therapy or classroom tasks. Context-specific comfort and familiarity matter too — familiar environments tend to support regulation, while unfamiliar ones require more effort from the child simply to orient and understand what is happening around them.
Perez and Bowers (2023) found that bilingual environments are associated with differences in self-regulation and play behaviors with implications for early intervention and therapy planning. That finding is telling us something important — that language, culture, expectations, and sensory regulation are deeply interconnected. When we see different sensory responses across settings, we need to consider environmental and linguistic demands before assuming a sensory processing disorder. The question to ask first is always: is this a sensory system that is not functioning typically, or is this a sensory system that is working hard to manage an environment that is demanding, unfamiliar, and linguistically complex?
What sensory differences might look like clinically includes increased distraction in language-heavy environments, where the child is already managing more cognitive load and is therefore overwhelmed by additional sensory input more quickly. We see withdrawal or hesitation in unfamiliar settings as the child figures out the space and what is expected of them. Variable tolerance for noise or group activities is common — it often depends on whether the child understands the language and expectations around them. When things feel comprehensible and familiar, tolerance tends to improve. We see changes in regulation across environments, and strong engagement in familiar contexts alongside real difficulty in new ones. A child might regulate and participate successfully in a therapy context that has become very familiar to them but appear overwhelmed in a new evaluation setting. Those differences often reflect adaptation to environments and linguistic demands rather than a change in underlying sensory ability — and that is a clinically important distinction that protects children from being over-identified with sensory processing disorders that may not exist.
Executive Function
Executive functioning may be influenced by task complexity, language demands, cognitive flexibility across contexts, and managing multiple rules and expectations simultaneously. When tasks include multiple steps or unfamiliar expectations, bilingual learners may need additional time to organize themselves and their actions. The more complex a task, the more attention and working memory it requires. When children are processing instructions in a language that is still developing, a large portion of their cognitive resources are devoted to understanding the language itself before they can even begin planning and completing tasks. Cognitive flexibility is another key factor. Shifting between environments, languages, and social rules is itself an executive function demand. Managing multiple rules and expectations — what is expected at home, what is expected at school, what is expected in therapy — adds to this cognitive load.
I want to emphasize the intersection of language demands and executive function, because I think this is one of the areas most commonly misinterpreted in evaluation. When a child is working in a language that is not their strongest, cognitive resources are being used to process the language first. That leaves fewer resources available for the planning, organization, and sequencing that we associate with strong executive function. So what can look like poor executive functioning — difficulty with multi-step tasks, variable attention, slow task initiation — may actually be a direct expression of increased language processing demand. Yang et al. (2024) found that diverse bilingual experience profiles are associated with differences in executive functioning that may influence task performance and participation. This research points us clearly toward interpreting executive function performance through a contextual lens.
What this looks like clinically includes slower task initiation during language-heavy activities, because the child is trying to understand the language before organizing the steps — they cannot begin executing a plan until they understand what is being asked. We see difficulty following multi-step directions in unfamiliar contexts for the same reason. Variable attention across environments is common: a child might sustain attention beautifully in a familiar, predictable routine and appear distracted in a new setting with new language demands. Changes in organization or task completion depending on the setting are also typical. Children may appear more organized in environments where routines are predictable and language is familiar. And strong performance in familiar routines alongside inconsistency in new ones is one of the hallmark patterns for bilingual learners across many domains. Overall, these patterns often reflect differences in cognitive load and environmental demands rather than a true executive functioning deficit. Before attributing executive function difficulties to a processing disorder, we should always ask: what are the language demands of this task, and how familiar is this environment to this child?
Play
Play is not as universal as we sometimes assume. It is shaped by culture, family values, and experience. When we think about play, we often think of it as spontaneous and universal, but play is actually shaped by culture, family values, and experience. Different families and communities emphasize different types of play and interaction. Some prioritize imaginative play. Some emphasize physical play, outdoor exploration, or board games and puzzles. Others emphasize participation alongside adults as the primary play mode, rather than child-directed independent play. Because of these differences, children may be more familiar with certain play materials, play routines, and play scripts than others.
Familiarity with materials matters in assessment. Some families regularly practice imaginative character play with dolls, action figures, or pretend scenarios — and children from those households will look very different in pretend play assessments than children who have not had those same materials and scripts modeled at home. That difference does not tell us about play ability. It tells us about play exposure and experience.
Language also plays an important role. Children may know the play scripts, character roles, or game rules in one language but not another. A child might be a confident, creative player in Spanish with family members at home, but appear much more hesitant or passive in English during a school play group where the language and the expected scripts are different. Social expectations across play settings differ as well — what is acceptable play behavior at home may differ from what is expected on the school playground or in a structured therapy session. A child might appear highly engaged in play in one environment but quieter, maybe more hesitant in another, and that does not necessarily mean they lack a skill.
What might play differences look like clinically? We see quiet observation before joining play — children watching, mapping the environment, figuring out the rules and the language before they step in. We see limited use of pretend play in unfamiliar settings because the child is unfamiliar with the play scripts, character roles, or language used in that activity. We see preference for familiar play partners or routines, difficulty following game rules in a new language, and strong play engagement in one environment but not another. What we often observe overall is that variability — children may demonstrate rich, complex play in one environment and appear much more hesitant in another. That variability reflects familiarity, experience, and context, not an absence of play ability. It is a context difference, not a skill deficit.
Self-Regulation
Regulation is always context-dependent, and I always invite clinicians to think about this in their own experience. You probably regulate differently at home on the couch than you do in meetings, and differently again when you are at a busy airport. Same person, different environment, different demands. Children are no different. When we see a child who appears regulated at home but dysregulated at school, or calm with one adult but not another, we should not first ask what is wrong with this child. We should ask: what are the demands of this environment, and how is this child experiencing them?
Self-regulation may be influenced by environmental predictability. Predictable environments tend to support regulation. Unfamiliar or high-stimulation environments may require more effort for a child to manage their behavior and attention. Think about what it takes to walk into a room where you do not know the language or the social expectations — you have to work so much harder just to orient yourself, let alone regulate your behavior while doing it. That extra work has a real cost on a child's regulatory resources.
Cultural expectations for behavior also matter. In some families, high activity levels and expressive behavior are expected and accepted. In others, quiet compliance and sustained attention are emphasized. These practices shape how children learn to regulate themselves and what regulated behavior looks like to them. When a child walks into a school environment with very different regulatory expectations from home, there can be genuine confusion about what is being asked of them — and that confusion itself is dysregulating.
Language load and task demands add another layer. When a child is working in a language that is not their strongest, cognitive load increases, and it may simply be harder to self-regulate because there is more to manage at once. Every bit of cognitive effort going toward processing language is a bit less available for managing behavior, attention, and emotions. Familiarity with routines and partners rounds this out. When expectations, language, or social dynamics change, regulation can become more difficult. We have to think about how much energy a bilingual child is using just to navigate the expectations of a new setting before we can even begin asking them to regulate themselves within it.
What self-regulation differences look like clinically: increased fatigue or frustration during language-heavy tasks, because if there is a lot of language involved it is simply more work and children get tired or frustrated faster. Withdrawal or reduced participation in unfamiliar environments is common — if things feel new or unclear, some children just hang back while they figure it out. Higher activity levels in structured settings may actually represent a regulatory strategy rather than off-task behavior. Extra movement is often the child's attempt to stay regulated, not an indication that they are ignoring directions. Changes in emotional responses across adults or environments are typical, as is calm regulation in familiar routines that breaks down in new contexts. They look great in routines they know, but once something changes, it gets harder. These patterns reflect the demands of the environment and the cognitive cost of navigating bilingual contexts, not a fundamental deficit in the child's regulatory capacity.
Daily Routines
Daily routine participation is shaped by family structure and schedules, cultural caregiving practices, language used during routines, and expectations for independence. Every family organizes their daily life differently. Some follow very structured schedules with predictable timing and transitions. Others are more fluid and flexible, with meals, sleep, and activities organized around what the family needs in the moment. Both of these approaches are valid, and both teach children something important. The child learns timing, learns transitions, learns what is expected of them within routines — and all of that learning happens in the language of the home, tied to the specific practices and values of that family.
Cultural caregiving approaches vary widely. Some families prioritize independence early. Children in some cultural contexts are expected to dress themselves, feed themselves, and manage their personal care quite young. In other families, shared caregiving and participation alongside family members is the valued approach — children are dressed by parents or older siblings for longer, are fed by caregivers or eat family-style meals from shared dishes, and are physically carried or held well into toddlerhood or beyond. These are not deficits. They are different cultural frameworks for how children develop daily living skills, and they produce children who are competent in ways that are valued by their families and communities. When those children arrive in school or therapy settings that have different expectations for independence, the mismatch can look like a skill deficit — when it is actually a difference in cultural caregiving practice.
The language used during a routine also matters. The language of bedtime, the language of the morning routine, the language of mealtime — those are often deeply embedded in the home language for bilingual children. When those same routines are presented in a second language with different vocabulary, different cues, and different expectations, what was automatic at home suddenly requires deliberate cognitive effort. The routine has not changed, but everything around it has.
Differences in daily routines may appear as independence in one environment but dependence in another — the child might be totally independent at home but need more help elsewhere because the routine looks different. Difficulty transitioning between activities in unfamiliar settings is common because the child is trying to figure out what comes next while also processing it in a new language. Slower completion of routines when language demands increase reflects the fact that it is not just doing the task — the child is processing it too. Increased reliance on familiar adults or cues is something we often see, as is successful participation at home but challenges in a new environment. A child might dress independently at home where the routine, the clothing, and the language cues are all familiar. But that same child might appear more dependent during dressing for physical education class at school because the sequence, the vocabulary, and the expectations are different. The skill is there. The routine and setting have changed. These differences often reflect how routines were learned and practiced rather than an absence of underlying skill.
Culturally Responsive Assessment and Intervention
Interpreting Assessment Through Context
Assessment does not occur in a neutral context. I want to read that again because it is foundational to everything in this section: assessment does not occur in a neutral context. Performance during evaluation is influenced by language familiarity, cultural expectations, environmental demands, and prior experiences and routines. Every single evaluation we conduct with a bilingual child is happening within a particular set of conditions — and those conditions shape what we observe just as much as the child's underlying abilities do. When we interpret results without accounting for those conditions, we are not seeing the child clearly. We are seeing the child through a filter that may significantly distort what we think we know.
Language familiarity affects how quickly a child processes instructions, how confidently they respond, and whether they can demonstrate what they actually know. When a child is working in a less familiar language, additional cognitive effort goes toward simply understanding the language before anything else. The child who nods and seems engaged may actually be spending most of their cognitive energy trying to parse what was just said — and has very little left over for demonstrating the skill we are trying to assess.
Cultural expectations matter deeply in the evaluation context. Some children are taught to wait quietly before responding, to avoid guessing if they are not certain, or to show respect to adults by limiting eye contact or deferring rather than initiating. These are not attentional or cognitive problems — they are culturally taught behavioral patterns. If we do not understand the cultural context, we can easily misinterpret them as disengagement, limited comprehension, or regulation difficulties.
The testing environment itself may be unfamiliar in ways that affect performance. The room, the materials, the format of the tasks, and the expectations for how to sit, respond, and engage may all differ significantly from anything the child has experienced before. And prior experience with assessment-style tasks plays a critical role. Many standardized assessments rely on familiarity with testing routines such as responding quickly to adult-directed questions, labeling pictures, or demonstrating skills on demand. Not all children have equal exposure to these expectations. A child who has never been asked to sort shapes on demand, point to pictures in a book, or repeat sentences back to an adult may respond very differently than a child who has practiced these routines — regardless of underlying ability.
This brings us to a fundamental reminder grounded in the Occupational Therapy Practice Framework (4th ed.; AOTA, 2020): occupational performance results from the dynamic interaction among the client, context, and activity demands. When we assess a child, we are not measuring ability in isolation. What we are seeing during evaluation is a snapshot of performance within a particular set of conditions. Our role as clinicians is to interpret that snapshot carefully by considering the context, the task demands, and the child's experiences. Assessment measures performance within context — not ability in isolation. And for bilingual learners, that distinction is particularly important.
When Difference May Be Mistaken for Delay
As therapists, we do not diagnose. Our goal is to assess participation and performance and contribute clinical insight to the team. When working with bilingual children, it is important to remember that observed performance during assessment can be influenced by language experience and communication access, cultural expectations and interaction styles, environmental demands, familiarity with tasks and routines, and opportunities for participation across settings. Some children may not have had the same exposure to certain activities — matching, sorting, pointing to pictures in books — and that exposure difference can influence how easily they demonstrate skills. That matters for our interpretation.
Research by Peña and Bedore (2011) and Rojas and Iglesias (2021) shows that bilingual children can be both over-identified and under-identified when assessment relies on monolingual expectations. Over-identification happens when language differences look like delays. Under-identification happens when a child appears to be doing fine in one language but real difficulties across both languages are missed. Neither outcome is acceptable, and both originate from the same error: comparing bilingual performance to monolingual norms. This is one of the most clinically important ideas in this entire course.
A question that comes up often in clinical settings is: how do we know the difference between a language difference and a disorder? This is a critical question. A key clinical guideline is that a disorder tends to show up across contexts and languages, while a difference tends to be context-dependent. If a difficulty is showing up in one language but not the other, or in one environment but not another, that is meaningful clinical information pointing toward context rather than disorder. But if the same difficulty — the same pattern of delay or challenge — is showing up across both languages and multiple environments, then we are more apt to consider whether there is an underlying disorder that needs further evaluation. We have to look across both languages, we have to look at exposure history, and we have to look at functional participation across settings. The OT Practice Framework reminds us that occupational performance results from the dynamic interaction among the client, context, and activity demands — meaning the interaction between the child, their environment, and the task demands is always shaping what we see during evaluation. Part of our clinical reasoning when we see differences in performance is to consider whether those differences may reflect context rather than delay.
Factors That Can Influence Assessment Outcomes
Now that we have established that assessment does not occur in a neutral context, the next step is identifying specifically what factors may influence how bilingual children perform during evaluation. Naming these clearly is what allows us to interpret results more accurately and prevents us from drawing conclusions that are not justified by the data.
The language of test administration is significant. When children are tested in a less familiar language, they may require additional processing time to understand instructions before they can even begin responding. That processing time is often not accounted for in standardized tests, and when a child's processing time exceeds the expected pace, the resulting performance can look like difficulty when it is actually the child working through an additional cognitive step that monolingual test-takers do not have to navigate.
Familiarity with testing routines and expectations is another factor. Many standardized assessments rely on familiarity with specific testing formats — responding quickly to adult-directed questions, labeling pictures when pointed to, or demonstrating skills on demand within time limits. Some families regularly engage in these kinds of interactions at home. Others do not. That difference in prior exposure to testing formats is not a deficit. It is a difference in experience. But it can significantly affect how a child performs on assessments that assume that familiarity.
Cultural communication styles can also influence participation in ways that are easy to misinterpret. Some children are taught to observe before responding, wait for explicit cues, or not answer if they are not certain of the answer. In some cultural contexts, responding incorrectly is more concerning than not responding at all, so a child will choose silence over a wrong answer. These are cultural orientations about communication, not cognitive limitations. But in an evaluation context, they can look like limited comprehension, poor engagement, or reduced responsiveness if we do not understand the cultural frame.
Task demands and instructions increase cognitive load when children are simultaneously processing language while trying to complete the task being measured. Those two demands compete with each other. When a child is devoting significant resources to understanding the language of the instruction, there are fewer resources left for executing the skill being assessed. Examiner-child interaction patterns also matter — the rapport between the clinician and the child, the pacing of the session, and the communication style all influence how comfortable and engaged the child feels. A child who is in an unfamiliar room, with an unfamiliar adult, working in their less dominant language is carrying a much larger regulatory and social load into the evaluation than the standardization sample likely was. And prior practice or exposure to evaluation-style tasks — manipulating puzzle pieces, sorting shape cards, pointing to pictures in books — shapes how easily a child can demonstrate skills on demand. All of these factors influence how performance appears during evaluation, even when underlying ability remains the same.
What Makes Assessment Accurate
Accurate assessment with bilingual learners requires multiple data sources rather than reliance on one test or one observed moment. We do not rely on a single test or a single snapshot. We need caregiver report, because families often have the clearest picture of how a child communicates and participates — and caregivers can describe routines, expectations, and strengths in their strongest language, which gives us a much more accurate occupational history. We need observation across settings. We need exposure history — understanding how much experience a child has had with each language, and in what contexts. And we need context analysis: what is this environment asking of this child right now?
When we put these pieces together, we get a much more accurate picture of the child's participation and abilities. We are not assuming that things look the same at school as they do at home. We are not assuming that the expectations at school are the same as what is expected at home. Especially with bilingual learners, we need that awareness that things might look very differently at home — expectations might look very different, cultural norms and the interpretation of events might be completely different for that family. Then the child gets into school and has to learn a whole new way of navigating all of those social and academic domains. Keeping that in mind is how we build a fuller, more accurate clinical picture.
A useful practical question that can help guide interpretation at any moment in the evaluation is this: is this a skill gap, or is this a context mismatch? Sometimes just asking that single question shifts everything about how we interpret what we are seeing. If a child can complete a task in one environment or in their home language, and cannot complete it in another environment or in their second language, that pattern is informative. It points toward context and exposure, not toward an underlying deficit. If the difficulty appears consistently across environments and across both languages, that is a different and more clinically significant pattern that warrants further exploration.
Dynamic assessment is another tool worth naming here. Unlike static standardized testing, dynamic assessment looks at how a child learns — what kind of support helps them perform, and how they respond to instruction within the assessment itself. That approach gives us information about the child's learning potential rather than their performance under unfamiliar, language-loaded conditions. When we are working with bilingual learners, dynamic assessment can be a particularly valuable addition to our clinical toolkit precisely because it is less dependent on the language of the assessment and more focused on the child's responsiveness to learning.
Interpreters as Therapeutic Partners
Interpreters in pediatric therapy are not simply translators whose job is to convert words from one language to another. Their role is much broader than translation. They help us access meaning, context, and participation. Using an interpreter allows us to see the child's true language competence — to evaluate what the child knows and what they can do rather than evaluating how well the child understands our language. This reduces one of the biggest risks in bilingual assessment: mistaking language difference for developmental delay. That distinction — difference versus delay — is one of the most important clinical determinations we make, and interpreters are essential clinical partners in making it accurately.
Interpreters also help us interpret behavior more accurately. A child who appears hesitant, nonresponsive, or slow to initiate might actually be processing the language, waiting for a turn-taking cue they use at home, or responding to communication patterns that differ from the testing environment. Without knowing the language or without using an interpreter, those behaviors can easily be misinterpreted as attention difficulties, regulation problems, or limited comprehension. Just as children adjust their motor plans depending on the environment they are in, bilingual children adjust their linguistic systems across contexts — and interpreters help us gather that information clearly, giving us hints, clues, and direct insight into how to interpret the differences we are observing.
Interpreters also strengthen assessment and goal development because they allow caregivers to fully participate in the process. Families can describe routines, expectations, and strengths in their strongest language, which gives us a much more accurate occupational history and profile. When caregivers can truly communicate in their primary language, we get a level of clinical detail and context that simply is not possible otherwise. The interpreter is not outside the therapeutic process — they are part of the clinical reasoning process. This approach is supported by professional guidelines across rehabilitation disciplines that emphasize providing culturally and linguistically appropriate care, including the use of qualified interpreters when language barriers affect evaluation or intervention. Interpreters help us access meaning, not just words.
Without an interpreter, the clinical risks are significant. We may mistake language difference for skill deficit. We may over- or under-estimate abilities. We may miss functional strengths that are visible only in home routines. We may create goals that do not generalize across environments because they were built on an incomplete and linguistically constrained picture of the child. Language access is an access issue — not a logistical inconvenience, but a clinical equity concern that directly affects the accuracy and fairness of our assessments and the relevance of our goals.
Reducing Bias in Clinical Interpretation
Reducing bias starts with recognizing that our interpretations are always influenced by something. We all have personal cultural assumptions. We were often trained within frameworks rooted in monolingual norms. We face time pressures during evaluation. We may have limited language access. These influences are not intentional biases, but they are often our default clinical frameworks. The reflection question I always return to here is: what expectations are we bringing into the room? As Ebert (2025) reminds us, comparing bilingual performance to monolingual norms can introduce assessment bias. Recognizing that is one of the first steps toward more accurate interpretation.
Practical strategies to reduce bias in evaluation include evaluating skills across contexts and languages whenever possible, using multiple data sources including observation, caregiver report, and dynamic assessment, collaborating with interpreters as clinical co-partners, examining exposure history before drawing conclusions, and distinguishing language difference from functional participation challenges. The underlying question running through all of these strategies is the same: is this a skill gap, or is this a context mismatch? Sometimes just asking that single question can shift how we interpret what we are seeing.
Culturally Responsive, Family-Centered Collaboration
Culturally responsive collaboration means making families genuine partners in the clinical process. It starts with asking families how skills look at home and clarifying routines before defining deficits. Before we decide something is a problem, we need to understand what the skill looks like in the environment where the child has had the most practice and the most support. It means valuing caregiver priorities and participation goals — some families care more about certain outcomes than others, and those priorities should meaningfully shape our intervention planning. It means collaborating with interpreters as clinical partners, not as a last resort. And it means aligning school-based or clinic-based goals with what is meaningful within the family's cultural and linguistic context.
One situation that comes up regularly in practice is working with a bilingual child from a culture or language that is different from the therapist's own background, where the family may also have concerns about stigma related to accessing services within their own community. The guiding principle here is always to respect family wishes. We can offer interpretive services, let families know we are not there to judge, and provide education about how assessment works and why language access matters for accuracy. But if a family has specific concerns or preferences about how services are delivered, we honor that. We can also consult with therapists or cultural informants who know the family's language and culture better, to strengthen our own understanding and clinical recommendations. We can research the culture. We can reach out to colleagues. We can be honest with families about the limits of our own cultural and linguistic competence and about how we are working to address those limits.
Parents and caregivers are always our best clinical resource. They carry knowledge about the child's history, routines, strengths, and daily life that no standardized assessment can capture. Asking a caregiver to describe how morning dressing goes at home, or how the child participates in a family mealtime, or what the child is like when playing with siblings in the home language — those conversations give us clinical information of an entirely different quality than anything we can observe in a therapy room. When we communicate that information to our whole team, including teachers, we build a much more accurate and complete clinical picture. The goal is always to ensure that our interpretation of performance reflects the child's actual abilities and actual participation, rather than a narrow slice of performance under conditions that may not be representative of what the child is truly capable of.
Case Applications
Applying the Lens
I always find that concepts come alive when we look at real-world scenarios. As we move into these case examples, I want you to keep a few questions in mind: What is the child being asked to do? In what context is performance occurring? What supports or barriers are present? How might language experience be influencing what we are seeing? What strengths are visible? There are no right answers here. The goal is clinical reflection.
Case Study for Mateo
Mateo is four years and six months old and was referred due to concerns about self-feeding and mealtime participation at preschool. He is a bilingual learner speaking Spanish at home and attending an English-speaking preschool, which is also his first structured school setting. Teachers report difficulty using utensils, frequent movement during meals, and challenges maintaining an upright seated posture at the table. At home, caregivers describe Mateo as independently feeding himself using his hands. They report that he sits on his mother's lap during meals. They have no concerns about feeding or participation during mealtimes at home.
Let us look at what is actually happening across these two settings. At school, lunchtime has a very specific structure. Children are expected to sit independently in a chair, stay at the table, use a spoon and fork, and follow the structured group mealtime routine. Mateo has limited familiarity with all of these expectations. At home, meals look different. He eats independently using his hands, often sitting on his caregiver's lap in a shared, flexible mealtime routine that is comfortable and works well for him and his family.
When teachers observe Mateo in the classroom, they see movement, postural challenges, and difficulty with utensils. It is easy to understand why concerns arise. But when we add the home context, something important becomes clear: the skill is there. He can feed himself. He shows coordination during independent feeding at home. He participates successfully in mealtime. This is not about whether he can do it — it is about how the environment changes how the skill presents itself. In a bilingual context, that environment includes language, and language is not neutral. It is tied to cultural norms, cultural routines, and expectations. What we are seeing is not an absence of skill. It is increased demand and possibly a lack of exposure to the specific expectations of the school mealtime environment.
Understanding Mateo's feeding patterns supports therapy in several important ways. First, we recognize that feeding competence is already present across contexts — we know right away that he can do this. Second, we distinguish differences in experience and exposure from motor delay, which prevents us from confusing a lack of experience with an actual delay. Third, we identify how posture, regulation, and environment are shaping performance and understand how much the setup and support are affecting what we observe. Fourth, we prevent culturally typical routines from being misinterpreted as deficits. We are not labeling something as a problem simply because it is a different way of doing things. And fifth, we expand participation skills rather than replacing meaningful routines. We are building skills for new settings, not taking away what already works.
Like bilingual language use, participation skills may vary across contexts while competence remains intact. That is the bottom line with Mateo.
The goal shift that follows from this lens is significant. A traditional, deficit-framed goal might read: Mateo will independently use utensils during meals in 4 out of 5 opportunities, or Mateo will maintain upright seated posture during meals for 10 minutes without external support. These goals are measurable and match typical school expectations, but they assume a skill deficit, they isolate utensil use and posture, and they ignore that competence is already present. When we shift the lens, the goal changes. Instead of correcting a single isolated skill, we focus on helping Mateo participate successfully in the school mealtime environment without disrupting the home routine that already works. A participation-framed goal might read: Mateo will demonstrate integrated feeding performance by maintaining midline trunk alignment and functional utensil use for a minimum of 8 minutes during school lunch in 4 out of 5 opportunities, while independently completing meals at home as reported by caregivers. We have shifted from replacing a routine to expanding participation across settings.
Case Study for Juan
Juan is six years old, a bilingual learner with a diagnosis of Autism Spectrum Disorder, currently receiving therapy services. In the classroom, teachers report several concerns. They describe him as clingy or overly dependent, particularly during transitions. He has difficulty separating from caregivers or his paraprofessional and tends to stay very close to familiar adults. His participation also decreases during language-heavy classroom activities. During therapy, a similar pattern is observed — he frequently seeks physical proximity to his para or therapist and sometimes sits on their lap during transitions or unfamiliar routines.
Before we interpret this case, I want to name something that I think is clinically important: when a child has an existing diagnosis like ASD, it can be very tempting to attribute all observed behaviors entirely to that diagnosis. This is where we need to slow down and think more carefully. Because Juan is not just navigating autism-related differences in regulation and predictability. He is also navigating multiple language environments and shifting expectations across settings. Those two sets of demands interact with each other, and together they create a significantly more complex regulatory landscape than either would alone.
With autism, there is often already a higher need for predictability, routine, and co-regulatory support to stay regulated. When something unexpected happens, when a transition is unclear, or when demands exceed the child's current regulatory capacity, seeking proximity to a familiar adult is a functional adaptive strategy. Now add a bilingual environment on top of that. More language to process, more shifting expectations depending on the setting, more to figure out when the context changes. That layered complexity increases the overall demand on Juan's regulatory and attentional systems. When we combine autism-related regulation needs with the cognitive demands of navigating a bilingual environment, we should not be surprised to see increased proximity-seeking, reduced participation during language-heavy activities, and more difficulty during transitions. What we are seeing is not dependence or regression — it is a regulatory system working very hard under compound demands.
What looks like clinginess or dependence is actually something much more functional. Staying close to a familiar adult is what allows Juan to participate. That adult provides regulatory scaffolding — helping Juan stay organized enough to engage with the environment around him. Co-regulation is a functional participation strategy. It is not getting in the way of participation — it is supporting it. Identifying how language load and environmental demands influence his behavior helps us understand why his participation decreases specifically during language-heavy activities: as those demands increase, he needs more support to stay organized and engaged. Our goal is not to remove the support. It is to scaffold regulation for participation, and then to gradually build from there.
Understanding Juan's participation supports therapy by recognizing co-regulation as a functional participation strategy, distinguishing regulation needs from lack of independence, identifying how language load and environmental demands influence behavior, preventing autism-related and culturally shaped behaviors from being misinterpreted as deficits, and supporting gradual expansion of independent participation across contexts. Supports are not barriers to independence when they enable participation.
The goal shift looks like this. A traditional performance-framed goal might read: Juan will independently transition between classroom activities without adult support in 4 out of 5 opportunities. That goal measures success by whether the support disappears — and in doing so, it frames the support as the problem. A participation-framed goal looks different: Juan will participate in classroom transitions using structured supports such as visual cues and predictable routines, demonstrating regulated behavior with reduced adult proximity in 4 out of 5 opportunities over 8 weeks. We start with visual supports and predictable routines because those are not barriers — they are tools. They are the bridge between what Juan needs to stay regulated and the participation we want to see. As he becomes more comfortable and regulated within predictable structures, we can gradually fade those supports over time. The measure of success is not whether the adult has stepped away. It is whether Juan can function successfully in the real classroom environment.
Case Study for Sofia
Sofia is nine years old, an elementary-age bilingual learner. The main concerns center on written work. Her written assignments are often slow, brief, or incomplete. She struggles to keep pace with classroom writing activities, and her written output appears lower than her verbal participation. Her observed strengths tell a different story: she verbally explains her ideas clearly, she retells stories and demonstrates comprehension during discussion, and she understands academic content when responding orally.
The clinical question this case asks is important: does reduced written output reflect limited ability, or does it reflect increased task demand?
I want to start with what we already know from her strengths. She can explain her ideas. She can retell information. She can participate in academic discussions. Her understanding of the content is intact. That is our baseline — and it tells us something essential before we even begin to analyze why her writing looks different.
Writing is not just a language task — it is a coordination task layered with language demands. When Sofia sits down to write a response to a classroom prompt, here is what she is managing simultaneously: she is generating ideas, organizing them logically, translating sentence structure between languages if her thoughts are forming in her home language while the assignment requires English, attending to grammar and spelling in her second language, maintaining seated posture, controlling the pencil with enough precision to produce legible output, sustaining attention to the task, and doing all of this within the classroom time limits and while managing the ambient noise and activity of a group setting. That is an enormous layered demand — what I sometimes think of as an executive and motor load unlike almost any other classroom activity.
For bilingual learners specifically, writing can require additional processing time because the ideas may be forming in one language while the child is trying to express them in written format in another. While speaking, Sofia can make small language errors and listeners still understand her clearly because meaning comes through in context, tone, and gesture. But in writing, she must generate the idea, organize it, translate it into written English, attend to spelling and grammar, and produce it motorically — all at the same time. Listening to her speak, you can understand what she knows. Looking at her written work alone, you might significantly underestimate it.
I find it genuinely helpful to imagine the following scenario to make this concrete: think about trying to write a professional email in your second language. You know what you want to say. You understand the topic. But in that specific format — written, formal, second language — you are going to need more time and considerably more effort than simply saying it out loud in a conversation. You might draft and revise. You might pause frequently to check your word choices. Your output will be shorter than it would be in your first language, and it will take longer to produce. That is the difference we are seeing with Sofia. Reduced written volume does not automatically indicate reduced knowledge or reduced cognitive ability.
Understanding Sofia's written output patterns supports therapy by recognizing that strong idea generation is already present despite reduced written volume, by differentiating written motor and language demands from cognitive understanding, by identifying the layered executive, language, and motor load that school writing tasks place on bilingual learners, and by preventing slow or limited handwriting output from being misinterpreted as low academic ability. Without this lens, Sofia risks being labeled as a low-achieving student when she is in fact a capable thinker who is being asked to demonstrate that capability through a format that carries exceptional cognitive and linguistic demands for her specifically.
The goal shift moves from measuring volume to supporting access. A traditional performance-framed goal might read: Sofia will increase written output to grade-level expectations, producing a complete paragraph in 4 out of 5 opportunities. That goal sounds reasonable and measurable — but it assumes that more writing means more ability, and it does not address the barriers that are actually making the writing hard. A participation-framed goal looks like this: Sofia will participate in grade-level writing tasks using structured supports such as planning templates and reduced copying demands, producing organized written responses that include at least 3 key ideas in 4 out of 5 opportunities over 8 weeks. The structured supports — the planning templates, the reduced copying — are not accommodations that lower expectations. They are access tools that allow Sofia's actual understanding to come through in her written output. We are measuring whether her ideas can make it onto the page, not simply how many words she produces. We have shifted from measuring volume alone to supporting access for full academic participation.
What All Three Cases Teach Us About Goal Writing
Across Mateo, Juan, and Sofia, even though these cases look different on the surface, they all share the same underlying clinical question: not what is wrong with the child, but what does this child need in order to participate successfully? And they all reveal the same clinical pattern: skills may exist in one context and look different in another; exposure shapes performance; context influences regulation and motor output; language load increases cumulative task demand; and participation varies across environments. The clinical shift across all three is the same — from correcting isolated performance to supporting flexible participation across contexts.
When performance is interpreted as a deficit, we assume the child lacks competence. We may expect the child to perform the same way across all settings. And the goals we write tend to focus on correcting or normalizing the skill in isolation. But we cannot write goals that truly serve bilingual learners from that framework. We need to look at things through a participation lens. We need to consider environmental demands, linguistic demands, and contextual differences. We need to expand participation, not try to normalize and remove things that are culturally meaningful or functionally important.
Let me walk through the goal shift across all three cases together to show the pattern clearly. With Mateo, the shift was from replacing a routine to expanding participation across settings — from "use utensils independently" to recognizing that feeding competence already exists and building school context skills alongside home competence. With Juan, the shift was from removing support to scaffolding regulation for participation — from "transition without adult support" to providing the predictable structures that allow him to participate while gradually building his regulatory capacity within those structures. With Sofia, the shift was from measuring volume alone to supporting access for full academic participation — from "produce a complete paragraph" to ensuring her ideas can actually make it onto the page given the layered demands writing places on her as a bilingual learner.
In each case, one goal assumed the problem was the child. The other assumed the problem was the match between the child's experience and the demands of the environment. One goal set out to fix the child. The other set out to build the bridge. I think about it this way: our goal-writing decisions are statements about what we believe the problem is. When we write a goal that corrects a behavior or a skill in isolation, we are saying: the child is the problem. When we write a goal that supports participation within a real context, we are saying: the environment has demands that this child is still learning to navigate, and our job is to build that capacity and reduce those barriers.
There is a practical structure I find helpful when reviewing goals for bilingual learners. Ask three questions about each goal. First: does this goal assume the child lacks a skill that they may actually possess in another context or in their home language? If yes, the goal needs revision. Second: does this goal require the child to perform in a way that is inconsistent with their home routines or cultural practices, and is that inconsistency necessary for functional participation? Sometimes it is — children do need to develop utensil use for school, for example. But the goal should reflect that we are expanding participation into a new context, not replacing the home routine. Third: does this goal include support structures that help the child build skills within real environments rather than demonstrate skills in isolation? Goals that include environmental supports, graduated scaffolding, and context-specific targets are far more likely to produce functional participation gains than goals that measure isolated skill performance.
This idea is grounded in the OT Practice Framework, which reminds us that participation occurs within context and is influenced by environmental demands (AOTA, 2020). Participation is not a fixed trait — it is a dynamic expression of the interaction between the child, the environment, and the task demands. The way we interpret performance is what ends up shaping our goals, and our goals shape what becomes possible in a child's daily life. Culturally responsive goals expand participation. They do not erase routines, they do not lower standards, they increase access. And when we practice this way, our interpretation becomes not only more inclusive, but more accurate.
Summary and Application
Translating the Framework Into Practice
We have covered a lot of ground today. Before we close, I want to give you something concrete to walk away with — a few simple checkpoints that can help guide your decisions going forward. In your next evaluation, consider: what is this child's exposure history across languages? Where does performance change across contexts? Are monolingual expectations influencing my interpretation? What participation demands matter most in this child's real environments? In your next goal-writing session, ask: does this goal expand flexible participation? Does it respect linguistic and cultural context? Does it avoid assuming uniform performance across settings? If the answer to any of those is no, that goal deserves another look.
The larger framework we have been building flows in a clear direction. Interpretation shapes goals, and goals shape what becomes possible in the child's daily life. When we consider context, exposure history, and participation, our interpretation becomes more accurate. It leads to participation-focused goals that allow performance to look different across environments. We see real participation in daily life, not just task performance in a therapy room. That is the clinical practice shift.
I want to revisit Mateo for a moment, because his case resonated with many practitioners and I want to make sure we fully close that loop. Mateo's participation looked different in two settings. It helps to put ourselves in his position. Think about how your own body changes depending on what you are doing — sitting in a restaurant booth, lounging on the couch, working at a computer. All of those look different because the demands are different. The same happens with children. Things like the seating setup, the expectations for independence, and the familiarity with the routine can make a significant impact on what performance looks like. Sometimes it simply means the situation is asking the child to perform a skill in a different way than they have ever practiced. That is not a delay. That is an invitation for us to build context bridges rather than deficit lists.
Another theme worth naming here is the role of time of day. I did not cover this explicitly in the main content, but it is a real variable in functional performance for bilingual learners. When we have a child coming from their home in their home language, and then there is a transition to the school setting in another language, by the afternoon that child may be genuinely exhausted from the processing demands of the day. Their behavior and performance in the afternoon might look completely different from how they looked in the morning. Time of day is worth noting in our documentation and in our clinical conversations with teachers and families.
And I want to name one more area that practitioners raised during this session: the role of augmentative and alternative communication devices with bilingual learners. AAC programming for bilingual children is an area where the principles we have discussed today are critically important. We need to ask caregivers what matters to them, what things the child needs to communicate, and how language is organized across the child's environments. The structure of different languages can be completely different — nouns and verbs may go in one order in one language and the complete opposite order in another. If we are not sure, and if we do not speak the other language, we need to use an interpreter and make sure we are getting it right. Language access in AAC is a clinical equity issue, and one where our bilingual lens matters enormously.
Key Takeaways
Let me bring us back to the core ideas that have guided this entire course. Bilingual development is variable, not deficient. Different developmental trajectories are not delays — they reflect the influence of exposure, timing, and context. Participation changes across contexts. A child may demonstrate competence in one setting and look quite different in another, and that variability is expected and meaningful, not pathological. Assessment measures performance within context, not ability in isolation. When we observe a child during evaluation, we are seeing a snapshot of performance within a particular set of conditions, not a transparent window into the child's fixed ability. Goals should expand participation, not eliminate meaningful routines. We are not here to normalize children's home routines or replace what works. We are here to build skills for new settings while honoring what is already present. And finally, culturally responsive practice strengthens clinical accuracy. When we practice this way, our interpretation becomes not only more inclusive but genuinely more accurate.
If I had to distill everything we have covered today into one sentence, it would be this: difference is not disorder. Context matters.
I will close with a final reflection question: what will you interpret differently tomorrow? I genuinely mean that as a clinical prompt. When you walk into your first session or evaluation tomorrow morning, what will you look at through a different lens because of what we have worked through today? Maybe it is mealtime participation and what it looks like across settings. Maybe it is that kindergartner who is not verbalizing, and whether that silence might be a silent period rather than a language disorder. Maybe it is your goal language — whether you are writing a goal that expands participation or one that corrects performance in isolation. Maybe it is simply the caregiver sitting in the waiting room who speaks a different language than you do, and recognizes that they are your most important source of clinical information about that child. Parents are often our best resource. They carry knowledge about the child's history, routines, and strengths that no standardized assessment can capture.
Supporting bilingual learners requires nuance, reflection, and contextual reasoning. Your clinical interpretation matters. Thank you so much for your time today and for your commitment to thoughtful, culturally responsive practice.
References
See additional handout.
Citation
Konradi, T. (2026). Pediatric bilingual-learner primer for therapists. PhysicalTherapy.com, Article 5026. Retrieved from https://PhysicalTherapy.com
