Peer Reviewed Articles Summary (BILINGUALISM AND LANGUAGE DISORDERS IN BILINGUALS)

– Students will select two peer reviewed articles (articles are selected and approved below)
– One article will be in bilingualism:

Bilingualism: consequences for mind and brain

https://reader.elsevier.com/reader/sd/pii/S1364661312000563?token=CC411BAF4C1DFECCAE372A514A4A683DB357FC6F420C78D0640139F6E25DA702777F6B8534C3A66D8D873149FA272CD8&originRegion=us-east-1&originCreation=20220118232039

– Second article will be in language disorders in bilinguals

Acquired Language Disorders in Bilinguals

https://emj.emg-health.com/wp-content/uploads/sites/2/2019/08/Acquired-Language-Disorders-in-Bilinguals

– Summarize both articles
– Discuss clinical findings relevant to our field
– Provide your personal opinion about the articles

Feature

Review

Bilingualism: consequences for mind
and brain
Ellen Bialystok1,2, Fergus I.M. Craik2 and Gigi Luk3

1
Department of Psychology, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada

2
Rotman Research Institute of Baycrest, 3560 Bathurst Street, Toronto, ON, M6A 2E1,Canada

3
Harvard Graduate School of Education, 14 Appian Way, Cambridge, MA 02138, USA

Review

Building on earlier evidence showing a beneficial effect
of bilingualism on children’s cognitive development, we
review recent studies using both behavioral and neuro-
imaging methods to examine the effects of bilingualism
on cognition in adulthood and explore possible mecha-
nisms for these effects. This research shows that bilin-
gualism has a somewhat muted effect in adulthood but a
larger role in older age, protecting against cognitive
decline, a concept known as ‘cognitive reserve’. We
discuss recent evidence that bilingualism is associated
with a delay in the onset of symptoms of dementia.
Cognitive reserve is a crucial research area in the context
of an aging population; the possibility that bilingualism
contributes to cognitive reserve is therefore of growing
importance as populations become increasingly diverse.

Why bilingualism?
It is generally believed that more than half of the world’s
population is bilingual [1]. In each of the U.S.A.1 and
Canada2, approximately 20% of the population speaks a
language at home other than English. These figures are
higher in urban areas, rising to about 60% in Los Angeles3

and 50% in Toronto4. In Europe, bilingualism is even more
prevalent: in a recent survey, 56% of the population across all
European Union countries reported being functionally bilin-
gual, with some countries recording particularly high rates,
such as Luxembourg at 99%5. Bilinguals, therefore, make up
a significant portion of the population. Importantly,
accumulating research shows that the development, efficien-

Corresponding author: Bialystok, E. (ellenb@yorku.ca)
1 U. S. Census Bureau (2010) The 2011 Statistical Abstract. Languages Spoken at

Home by Language: 2008, Table 53. Retrieved August 4, 2011 from http://www.census.
gov/compendia/statab/cats/population/ancestry_language_spoken_at_home.html.

2 Statistics Canada (2007) 2006 Census of Canada highlight tables: Population by
language spoken most often at home and age groups, 2006 counts, for Canada, provinces
and territories – 20% sample data. (Catalogue number 97-555-XWE2006002). Retrieved
August 4, 2011 from http://www12.statcan.ca/census-recensement/2006/dp-pd/hlt/
97-555/T402-eng.cfm?Lang=E&T=402&GH=4&SC=1&S=99&O=A.

3 U. S. Census Bureau (2010) The 2011 Statistical Abstract. Language Spoken at
Home – Cities With 100,000 Persons or More: 2008, Table 55. Retrieved August 4, 2011
from http://www.census.gov/compendia/statab/cats/population/ancestry_language_
spoken_at_home.html.

4 Statistics Canada (2007) 2006 Census of Canada highlight tables: Population by
language spoken most often at home and age groups, 2006 counts, for Canada, provinces
and territories – 20% sample data. (Catalogue number 97-555-XWE2006002). Retrieved
August 4, 2011 from http://www12.statcan.ca/census-recensement/2006/dp-pd/hlt/
97-555/T402-eng.cfm?Lang=E&T=402&GH=4&SC=1&S=99&O=A.

5 European Commission (2006) ‘Special Eurobarometer

243

: Europeans and their
Languages (Executive Summary)’ (PDF). Europa web portal. p. 3. Retrieved Novem-
ber 1, 2011 from http://ec.europa.eu/public_opinion/archives/ebs/ebs_243_sum_en .

240 1364-6613/$ – see front matter � 2012 Elsevier Ltd. All rights reserv

cy, and decline of crucial cognitive abilities are different for
bilinguals than for monolinguals. What are these cognitive
differences and how does bilingualism lead to these changes?

The context for examining how bilingualism affects cog-
nitive ability is functional neuroplasticity, that is, the study
of how experience modifies brain structure and brain func-
tion. Such modifications have been found following experi-
ences as diverse as juggling [2], video-game playing [3],
careers in architecture [4], taxi-driving [5], and musical
training [6,7]. Bilingualism is different from all of these:
like juggling and playing video games, it is intense, and, like
architecture and driving taxis in London, it is sustained, but,
unlike these experiences, bilinguals are not typically pre-
selected for talent or interest. Although bilinguals undoubt-
edly differ from monolinguals in certain ways, they gener-
ally did not choose bilingualism. Rather, the circumstances
of their family, place of birth, or immigration history simply
required that they learn more than one language.

What is different about bilingual minds?
It has long been assumed that childhood bilingualism
affected developing minds, but the belief was that the
consequences for children were negative: learning two
languages would be confusing [8]. A study by Peal and
Lambert [9] cast doubt on this belief by reporting that
children in Montreal who were either French-speaking
monolinguals or English–French bilinguals performed dif-
ferently on a battery of tests. The authors had expected to
find lower scores in the bilingual group on language tasks
but equivalent scores in non-verbal spatial tasks, but
instead found that the bilingual children were superior
on most tests, especially those requiring symbol manipu-
lation and reorganization. This unexpected difference be-
tween monolingual and bilingual children was later
explored in studies showing a significant advantage for
bilingual children in their ability to solve linguistic prob-
lems based on understanding such concepts as the differ-
ence between form and meaning, that is, metalinguistic
awareness [10–16] and non-verbal problems that required
participants to ignore misleading information [17,18].

Research with adult bilinguals built on these studies with
children and reported two major trends. First, a large body
of evidence now demonstrates that the verbal skills of
bilinguals in each language are generally weaker than
are those for monolingual speakers of each language.

ed. doi:10.1016/j.tics.2012.03.001 Trends in Cognitive Sciences, April 2012, Vol. 16, No. 4

mailto:ellenb@yorku.ca

http://www.census.gov/compendia/statab/cats/population/ancestry_language_spoken_at_home.html

http://www12.statcan.ca/census-recensement/2006/dp-pd/hlt/97-555/T402-eng.cfm?Lang=E&T=402&GH=4&SC=1&S=99&O=A

http://www.census.gov/compendia/statab/cats/population/ancestry_language_spoken_at_home.html

http://www12.statcan.ca/census-recensement/2006/dp-pd/hlt/97-555/T402-eng.cfm?Lang=E&T=402&GH=4&SC=1&S=99&O=A

http://ec.europa.eu/public_opinion/archives/ebs/ebs_243_sum_en

http://dx.doi.org/10.1016/j.tics.2012.03.001

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

Considering simply receptive vocabulary size, bilingual
children [19] and adults [20] control a smaller vocabulary
in the language of the community than do their monolingual
counterparts. On picture-naming tasks, bilingual partici-
pants are slower [21–24] and less accurate [25,26] than
monolinguals. Slower responses for bilinguals are also found
for both comprehending [27] and producing words [28], even
when bilinguals respond in their first and dominant lan-
guage. Finally, verbal fluency tasks are a common neuro-
psychological measure of brain functioning in which
participants are asked to generate as many words as they
can in 60 s that conform to a phonological or semantic cue.
Performance on these tasks reveals systematic deficits for
bilingual participants, particularly in semantic fluency con-
ditions [29–33], even if responses can be provided in either
language [34]. Thus, the simple act of retrieving a common
word is more effortful for bilinguals.

In contrast to this pattern, bilinguals at all ages demon-
strate better executive control than monolinguals matched in
age and other background factors. Executive control is the set
of cognitive skills based on limited cognitive resources for
such functions as inhibition, switching attention, and work-
ing memory [35]. Executive control emerges late in develop-
ment and declines early in aging, and supports such activities
as high-level thought, multi-tasking, and sustained atten-
tion. The neuronal networks responsible for executive control
are centered in the frontal lobes, with connections to other
brain regions as necessary for specific tasks. In children,
executive control is central to academic achievement [36],
and, in turn, academic success is a significantpredictor of long
term health and well being [37]. In a recent meta-analysis,
Adesope et al. [38] calculated medium to large effect sizes for
the executive control advantages in bilingual children, and
Hilchey and Klein [39] summarized the bilingual advantage
over a large number of studies with adults. This advantage
has been shown to extend into older age and protect against
cognitive decline [21,40,41], a point to which we turn below.

In this review, we examine the evidence for bilingual
advantages in executive control and explore the possible
mechanisms and neural correlates that may help to ex-
plain them. Our conclusion is that lifelong experience in
managing attention to two languages reorganizes specific
brain networks, creating a more effective basis for execu-
tive control and sustaining better cognitive performance
throughout the lifespan.

Language processing in bilinguals
Joint activation of languages

A logical possibility for the organization of a bilingual mind
is that it consists of two independently-represented lan-
guage systems that are uniquely accessed in response to
the context: a fluent French–English bilingual ordering
coffee in a Parisian café has no reason to consider how to
form the request in English, and a Cantonese–English
bilingual studying psychology in Boston does not need to
recast the material through Chinese. Yet, substantial evi-
dence shows that this is not how the bilingual mind is
organized. Instead, fluent bilinguals show some measure of
activation of both languages and some interaction between
them at all times, even in contexts that are entirely driven
by only one of the languages.

The evidence for this conclusion comes from psycholin-
guistic studies using such tasks as cross-language priming
(in which a word in one language facilitates retrieval of a
semantically related word in the other language) and
lexical decision (in which participants decide whether a
string of letters is an actual word in one of the languages)
that show the influence of the currently unused language
for both comprehension and production of speech [42–48].
Further evidence comes from patient studies showing
intrusions from the irrelevant language or inappropriate
language switches [49], and imaging studies indicating
involvement of the non-target language while performing
a linguistic task in the selected language [50–52]. Using
eye-tracking technology, for example, Marian, Spivey, and
Hirsch [53] reported that English–Russian bilinguals per-
forming a task in English in which they had to look at the
named picture from four alternatives were distracted by a
picture the name of which shared phonology with Russian,
even though there was no connection to the meaning of the
target picture and no contextual cues indicating that Rus-
sian was relevant. Similarly, Thierry and Wu [54] pre-
sented English monolinguals, Chinese–English bilinguals,
and Chinese monolinguals with pairs of words in English
(translated to Chinese for Chinese monolinguals) and
asked participants to decide if the words were semantically
related or not. The manipulation was that half of the pairs
contained a repeated character in the written Chinese
forms, even though that orthographic feature was unrelat-
ed to the English meaning. Waveforms derived from anal-
yses of electroencephalography (EEG) are used to indicate
the neuronal response to language on a millisecond by
millisecond scale. An event-related potential (ERP) called
the N400 (i.e. a negative-going waveform peaking approxi-
mately 400 msec after the onset of a target stimulus)
signals the effort associated with integrating the meaning
of words. The more similar the words are to each other, the
smaller is the amplitude of the N400. In the study by
Thierry and Wu, semantic relatedness was associated with
significantly smaller N400 amplitude in all groups as
expected, but the repeated character also led to smaller
N400 for the two Chinese groups. Thus, although irrele-
vant to the task, participants were accessing the Chinese
forms when making judgments about the semantic relation
between English words. Subsequent research has refined
these results by showing their basis in the phonology
rather than the orthography of spoken language [55]
and extended the phenomenon to the phonological hand
forms of American Sign Language [56].

This joint activation is the most likely mechanism for
understanding the consequences of bilingualism for both
linguistic and non-linguistic processing. For linguistic pro-
cessing, joint activation creates an attention problem that
does not exist for monolinguals: in addition to selection
constraints on such dimensions as register, collocation, and
synonymy, the bilingual speaker also has to select the
correct language from competing options. Although joint
activation creates a risk for language interference and
language errors, these rarely occur, indicating that the
selection of the target language occurs with great accuracy.
However, this need to select at the level of language system
makes ordinary linguistic processing more effortful for

241

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

bilinguals than monolinguals and explains some of the
costs in psycholinguistic studies described above. For
non-linguistic processing, the need to resolve competition
and direct attention is primarily the responsibility of gen-
eral cognitive systems, in particular executive functions.
The possible influence of linguistic processes on non-lin-
guistic executive control has significant consequences for
lifespan cognition and is discussed in the next section.

Consequences of joint activation

An appealing suggestion for how the executive control
system achieves linguistic selection in the context of joint
activation is through inhibition of the non-target language.
At least two influential models have been proposed that
place inhibition at the center of this selection. The first, the
Inhibitory Control model [57] is based on the Supervisory
Attentional System [58] and extends a domain-general and
resource-limited attention system to the management of
competing languages. The second, the Bilingual Interac-
tive Activation Model (BIA+) [59], uses computer simula-
tion to model lexical selection from both intralingual and
extralingual competitors. Although both models assign a
primary role to inhibition, they are very different from each
other and address a different aspect of the selection prob-
lem. It is useful, therefore, to consider the distinction
between global inhibition and local inhibition proposed
by De Groot and Christoffels [60]. Global inhibition refers
to suppression of an entire language system, as in inhibit-
ing French when speaking English, and local inhibition
refers to inhibition of a specific competing distractor, such
as the translation equivalent of the required concept. Both
processes are required for fluent language selection but the
two are carried out differently. Guo, Liu, Misra, and Kroll
[61] used functional magnetic resonance imaging (fMRI) to
demonstrate the recruitment of different systems for each
of global inhibition (dorsal left frontal gyrus and parietal
cortex) and local inhibition (dorsal anterior cingulate cor-
tex, supplementary motor area) in a sample of Chinese–
English bilinguals, and validated their distinct roles in
bilingual language control. Although Green’s inhibitory
control model is consistent with both types of inhibition,
Dijkstra’s BIA+ model is limited to modeling item selection
in local inhibition.

These types of inhibition also differ in their primary
domain of influence, with local inhibition largely affecting
linguistic performance and global inhibition affecting both
linguistic and cognitive performance. The linguistic out-
comes of inhibition are reduced speed and fluency of lexical
access for bilinguals as described above. However, perfor-
mance also requires a selection bias towards the target
language, showing a role for activation [62,63] as well as
inhibition. These alternatives are not mutually exclusive
but indicate the need for a more complete description of
how attention is managed in bilingual language proces-
sing. Ultimately the degree of both inhibition and activa-
tion are relative rather than absolute and will be
modulated by contextual, linguistic, and cognitive factors.
The cognitive outcomes of linguistic inhibition are en-
hanced attentional control and will be described more fully
in the next section. Importantly, the cognitive and linguis-
tic outcomes are related. Three studies have reported a

242

relationship between inhibition and ability in verbal and
non-verbal tasks by showing a correlation between Stroop
task performance and competing word selection [64], Si-
mon task performance and language switching in picture
naming [65], and cross-language interference and a variety
of executive control measures [66]. Such results point to an
extensive reorganization of cognitive and linguistic pro-
cesses in bilinguals.

Cognitive networks in bilinguals
Bilingual performance on conflict tasks

Early evidence that bilingual children solved non-verbal
conflict tasks differently from monolingual children was
reported in a study by Bialystok and Majumder [17]. Eight-
year-old children were given a variety of non-verbal
problems to solve, some of which contained perceptual
distraction (block design from the Wechsler Intelligence
Scale for Children, WISC [67]) and some which did not
(Noelting’s Juice Task [68,69]). Bilingual children outper-
formed monolinguals on the conflict tasks, but children in
the two groups were comparable on tasks that did not
include distracting perceptual information. This pattern
has been confirmed in studies of both children and adults
using a flanker task (children: [70,71]), theory of mind task
(children: [72,73]; adults: [74]), Simon task (children: [75];
adults: [40]). Other studies with adults have shown better
performance by bilinguals in naming the font color in a
Stroop task [21], smaller costs in task switching [76], better
ability to maintain task set in an attention task [77], and
more susceptibility to negative priming, presumably be-
cause of greater inhibition [78].

Some studies have extended these bilingual advantages
into older age. Bialystok, Craik, Klein and Viswanathan
[40] reported an experiment in which middle-aged and
older adults who were either monolingual or bilingual were
given a version of the Simon task. Participants were shown
either a green or a red square on each trial, and the task
was to press an associated response key as rapidly as
possible. The keys were located at each side of the presen-
tation screen. In one condition, the squares appeared
centrally on the screen, so there was no spatial conflict
between the location of stimuli and responses; in this
condition there were no reaction-time (RT) differences
between language groups. In a second condition, the col-
ored squares appeared laterally on the screen, either di-
rectly above the appropriate response key (congruent
condition) or on the other side of the screen, above the
incorrect response key (incongruent condition). The RT
difference between congruent and incongruent response
trials (the Simon effect) is a measure of attentional control.
Bilinguals produced smaller Simon effects than monolin-
guals at all ages.

Three other results from this study are noteworthy.
First, the decrease in attentional control in older adults
was reduced in the bilingual groups, suggesting that bilin-
gualism may be protective against the effects of cognitive
aging. Second, whereas a bilingual advantage was
expected for incongruent stimuli, it was also found for
congruent stimuli. This result has been replicated in sub-
sequent studies [39] and is difficult to account for in terms
of response conflict or inhibition. Third, prolonged practice

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

reduced both the Simon effect and the size of the bilingual
advantage. Apparently all participants can learn to disre-
gard the distracting effects of interfering stimuli given
sufficient practice on a task, but it seems that bilinguals
can learn this type of inhibition more rapidly. One inter-
esting question in this regard is the extent to which this
attenuation of attentional control is specific to the prac-
ticed situation, or whether it generalizes to tasks tapping
attentional control in a different manner. Our conjecture is
that the attenuation effect is context specific.

A complication that has emerged as more results are
reported is that the bilingual advantage is not always
found in samples of young adults. For example, a study
examining performance on the Simon task in 5-year-olds,
young, middle-aged and older adults found a bilingual
advantage in RT in the 5-year-olds and in the older adults,
but not in the young adult group [79]. Similarly, a study of
the Stroop effect in younger and older adults found a
bilingual advantage in both age groups but when the same
participants performed the Simon arrow task the bilingual
advantage was found only in the older adults [21]. Simi-
larly, Salvatierra and Rosselli [41] used a simple version of
the Simon task and reported a bilingual advantage for
older but not younger adults. There is thus some evidence
that the bilingual advantage is greatest in children and in
older adults, but less constantly present in young adults –
perhaps because the young adult group is at the develop-
mentally peak age for cognitive control.

It appears that bilingual advantages for young adults
tend to emerge on tasks or conditions that are difficult. For
example, Bialystok [80] found that bilingual young adults
outperformed their monolingual counterparts on the direc-
tional arrow Simon task, but only on the condition that
included more monitoring and switching than a simpler
condition. Similarly, several studies by Costa and collea-
gues have reported a bilingual advantage in young adults
[71,81,82] but only under some conditions. For example,
Costa et al. [81] demonstrated that the bilingual advantage
on a flanker task held only under high monitoring condi-
tions. In versions where most of the trials were of one type
(congruent or incongruent), no bilingual advantage was
observed; the advantage was found, however, in a condition
involving 25% incongruent and 75% congruent trials, al-
though even there the advantage decreased over blocks of
the experiment (cf. [44]). Costa et al. [81] concluded that the
bilingual advantage reflects a more efficient monitoring
system for conflict resolution, in that bilinguals may be
better at determining when the misleading information
can be safely ignored. Finally, Hernández et al. [82] used a
non-linguistic version of the Stroop effect and found a trend
towards both reduced interference and enhanced facilita-
tion in young adult bilinguals compared with monolinguals
(cf. older participants in [21]). One interesting aspect of the
studies by Costa, Hernández and colleagues is that the
monolinguals were Spanish speakers and the bilinguals’
two languages were Catalan and Spanish. Most of the
participants were undergraduate students and were not
immigrants, so the two groups were well equated apart
from the language difference. In summary, the evidence for
a bilingual advantage in younger adults is more sporadic
than in other age groups, although at all ages there are

some reports of studies showing no difference between
monolinguals and bilinguals performing a conflict task.

Neural correlates of cognitive reorganization

Recently, studies have begun to investigate the neural
correlates of bilingual processing examined in the behav-
ioral research. The majority of this research has used fMRI
to study bilinguals performing a linguistic task in their two
languages. Typically, participants name pictures or gener-
ate words in response to a cue signaling the required
language, and performance is compared for single lan-
guage and mixed language conditions. Two early studies
revealed promising results. The first led to the surprising
finding that language switching was accompanied by acti-
vation in the dorsolateral prefrontal cortex (DLPFC), an
area known to be part of the general executive control
system [24]. Less surprising was a study showing the
involvement of Broca’s area as well as a left frontal
area in a language switching task [83]. Subsequent re-
search has corroborated the involvement of these systems
and has shown that language switching elicits a spatially-
distributed activation pattern involving bilateral frontal
and precentral areas, bilateral caudate, bilateral (or mid-
line) pre-supplementary areas (pre-SMA), and bilateral
temporal regions. This pattern has been found for Ger-
man-French bilinguals [84], Spanish-Catalan bilinguals
[85], Chinese–English bilinguals [61,86,87] and Span-
ish–English bilinguals [88]. A few studies [61,84] have also
reported activation in anterior cingulate cortex (ACC), but
activation in this area is not consistently observed. Abu-
talebi and colleagues [89] extended this finding to show
activation of ACC for both language switching and non-
verbal switching. Importantly, these studies confirm that
frontal systems involved in executive control are recruited
by bilinguals to manage attention to language.

Abutalebi and Green [90] conducted a qualitative review
of these studies and proposed that the ACC, left prefrontal
cortex, left caudate and bilateral supramarginal gyri (SMG)
constitute the neural correlates of the control mechanism for
bilingual language production. This model was confirmed in
a quantitative meta-analysis examining bilingual language
switching [91] (Figure 1). Both the qualitative and quanti-
tative analyses point to multiple cortical regions in which
functional activity is altered by bilingualism, but an out-
standing question is whether activity in these regions is
synchronous, forming a neural network that is responsive to
bilinguals’ experience of managing two languages. To this
end, a study by Nakamura and colleagues [92] showed
strong connectivity between left inferior frontal gyrus
(IFG) and left middle temporal gyrus (MTG) in a group of
Japanese–English bilinguals performing a cross-language
priming task. The connectivity was stronger in the frontal-
temporal coupling than in the reverse direction. This pat-
tern was replicated using transcranial magnetic stimulation
(TMS) with Japanese–English bilingual participants per-
forming the same cross-language priming task. Nakamura
and colleagues [92] interpreted the results as indicating top-
down control from left IFG to left MTG in a bilingual context.

Taken together, fMRI research on bilingual language
switching has implicated distributed cortical activation
that converges in the frontal regions. Intriguingly, the

243

Left Right

TRENDS in Cognitive Sciences

Figure 1. Bilingual influence on brain function and structure. Transparent brains showing the left and right hemispheres. Green voxels depict grey matter regions showing

high activation during bilingual language switching in a meta-analysis [90]. Red–yellow voxels indicate regions of higher white matter integrity in bilingual older adults

relative to monolinguals [107]. Together, the functional and structural data indicate that neural correlates of bilingualism are observed in the frontal lobes, generally

responsible for higher cognition such as executive functions.

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

brain regions related to bilingual switching are also critical
for general attention and cognitive control [93,94]. This
overlap in brain regions activated for bilingual switching
and cognitive control implies that the same mechanisms
may be involved in both activities, and that these shared
processes might help to explain the superior performance
of bilinguals on non-verbal conflict tasks. In other words,
using these cognitive control networks for bilingual lan-
guage processing may reconfigure them for other purposes,
providing part of the explanation for the behavioral differ-
ences between monolinguals and bilinguals found in non-
verbal conflict tasks. Specifically, the evidence suggests
that cognitive control networks may be more broadly based
in bilinguals as a result of their dual function. However,
fMRI studies on language switching in bilinguals can only
show that these networks are included in bilingual lan-
guage selection. Determining whether or not such recon-
figuration occurs can only be evaluated by comparing
monolinguals and bilinguals performing non-verbal con-
flict tasks. The hypothesis is that monolinguals and bilin-
guals will perform non-verbal control problems using
somewhat different networks, specifically, that the net-
work used by bilinguals will be more broadly based.

Only a few studies have contrasted the neural correlates
of non-linguistic cognitive control in bilinguals and mono-
linguals. Garbin and colleagues [95] gave a color-shape
switching task to Spanish monolingual and Spanish-
Catalan bilingual young adults in fMRI. A bivalent stimu-
lus (e.g. a red circle) and a cue (e.g. ‘color’ or ‘shape’) were
shown, and participants responded to the indicated dimen-
sion. Both RT of switch costs and accuracy favored the
bilingual participants, but activation patterns were also
different for the two groups: monolinguals showed in-
creased activation in the right IFG, whereas bilinguals
showed increased activation in left inferior frontal gyrus.
More interestingly, higher levels of activation in left IFG
and left striatum were associated with smaller switch costs
for the bilingual participants, but increased activation in
the right IFG was associated with larger switch costs. In

244

light of the lack of switching effect in the behavioral data, it
is possible that the bilinguals relied more on the left IFG
and striatum in face of the demand to switch between
responses associated with a bivalent stimulus. The left
IFG was identified in both the qualitative [90] and quanti-
tative [91] meta-analyses of bilingual language switching.
This region is central to speech production [96] and has
been shown to have higher activation for bilinguals than
monolinguals during speech production [97,98]. Thus, left
IFG appears to be one of the overlapping brain regions in
bilinguals handling both language switching and non-lin-
guistic cognitive control.

A study by Luk and colleagues [99] used an adaptation
of a flanker task to compare activation in monolingual and
bilingual participants. The stimuli consisted of a string of
five chevrons, and the task was to indicate the direction of
the red one (that could appear in one of three positions)
while ignoring the four black ones. In a previous behavioral
study with these stimuli, bilinguals performed this task
more rapidly than monolinguals [100]. The fMRI data were
analyzed using a multivariate statistical technique for
neuroimaging data (Partial Least Squares; for review,
see [101]) to identify integrated neural networks. The
results showed that monolinguals and bilinguals recruited
different neural networks for both congruent and incon-
gruent trials. Another condition that tested ‘no-go’
responses indicated no difference between groups. Impor-
tantly, greater activity in the bilingual network, including
areas identified in the meta-analysis [91], was related to
smaller RT costs for incongruent trials. There are two
implications of these results. First, bilingualism alters
functional neural network at the response-selection level
(congruent and incongruent trials), but not at the motor
execution level (response inhibition no-go trials), a pattern
consistent with previous results for both adults [102] and
children [75,103]. Second, bilinguals showed a brain-
behavior correlation when suppressing interference from
conflicting flankers, replicating a previous study using
magnetoencephalography (MEG) [104].

Box 1. Bilingualism in infancy

Research with infants being raised in bilingual homes has produced

dramatic evidence for very early effects of bilingualism and

challenges some standard explanations for the mechanism under-

lying these effects. It has long been known that children being raised

with two languages do not confuse the languages when learning to

speak, even though they may borrow from one when speaking the

other [127]. It is also well known that monolingual infants lose the

ability to make phonetic discriminations not present in their

language by approximately 10 months old, whereas bilingual

infants continue to distinguish between phonetic categories rele-

vant to all languages. Thus, it is not surprising that bilingual infants

can differentiate between their two languages essentially from birth

[128]. What is surprising, however, is the extension of this

discrimination to non-acoustic properties of language. Weikum

and colleagues [129] showed silent video clips to 8-month-old

infants who were being raised in homes that were either mono-

lingual English or English–French bilingual. Using a habituation

paradigm, the speaker switched languages after habituation and the

researchers measured whether or not infants regained interest. The

results showed renewed attention among the bilingual but not the

monolingual infants. To determine whether the bilingual infants had

learned about the facial structures that accompany each language or

something more general, the same materials were presented to

monolingual Spanish (or Catalan) infants and bilingual Spanish–

Catalan infants [130]. Again, only the bilingual infants noticed the

change in language, even though the children in this study had no

experience with either language. The authors concluded that

bilingualism enhances general perceptual attentiveness through

the experience of attending to two sets of visual cues.

This enhanced perceptual attentiveness may help explain the

results of a study in which 7-month-old monolingual and bilingual

infants learned a head-turn response to a cue to obtain a visual

reward and then had to replace that with a competing response for

the same reward [131]. Again, only the bilingual infants could learn

the new response. Even before children have productive language

ability, the experience of building two distinct representational

systems endows them with greater perceptual and attentional

resources than their monolingual peers. In light of such evidence

for bilingual advantages in the first year of life, explanations for the

mechanism responsible for the advantages found later may need to

be reconsidered to include a role for such perceptual processes.

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

Although bilingualism is a language experience, man-
aging attention to two languages imposes demands on the
cognitive system that require brain regions not typically
used for language processing. From studies of bilingual
language switching and non-linguistic cognitive control,
and from the meta-analysis cited earlier, it seems likely
that the neural locus of cognitive control in bilinguals lies
in bilateral frontal regions. In order to facilitate informa-
tion transfer between the hemispheres, it is also possible
that prolonged bilingual experience alters anatomical
structures in addition to cortical functional networks. Cor-
tical activity assessed by fMRI is limited to blood oxygen-
ation level-dependent (BOLD) signal in the grey matter.
However, when investigating domain-general neural
changes (cognitive control) in response to domain-specific
experience (bilingualism), it is important to use methods
that allow not only the identification of functional net-
works but also their underlying anatomical structures
[105,106].

There is some evidence for the plasticity of cortical grey
matter in response to bilingualism. Mechelli et al. [107]
reported higher grey matter density in left inferior parietal
regions in a group of Italian–English bilinguals relative to
English monolinguals. Strikingly, proficiency in English,
the second language, correlated positively with grey mat-
ter density in this region. A recent study has extended
brain plasticity to white matter. Luk, Bialystok, Craik and
Grady [108] (Figure 1) used diffusion tensor imaging (DTI)
and fMRI to measure white matter integrity and resting-
state functional connectivity in monolingual and bilingual
older adults. The results showed higher white matter
integrity in bilingual older adults, primarily in the corpus
callosum connecting the two hemispheres but also extend-
ing to bilateral superior longitudinal fasciculi, right inferi-
or frontal-occipital fasciculus and uncinate fasciculus.
Identifying a seed close to the white matter voxels showing
a group difference, Luk et al. conducted a resting-state
functional connectivity analysis and showed that while
both monolinguals and bilinguals had correlating brain
activity with contralateral regions at rest, bilinguals had
increased anterior-posterior connectivity. This evidence
suggests that bilingualism is associated with better main-
tenance of white matter structures in the course of normal
aging [109]. Similar DTI results have also been recently
reported in bilingual children around the left inferior
frontal-occipital fasciculus [110].

The nature of the bilingual advantage
Why might bilingualism be associated with an advantage
in attentional control? The need to manage two jointly
activated languages apparently leads to an enhancement
of frontal-posterior attentional control mechanisms with
the consequence that other types of cognitive control are
also enhanced. Inhibitory control was suggested as the
relevant mechanism in early studies [40,57] and continues
to be endorsed by some researchers [47,111]. One problem
with this account, however, is the recurrent finding of a
bilingual advantage in congruent trials (for which there is
no conflict) as well as incongruent trials [40,71]. Minimally,
therefore, inhibition alone is insufficient to explain bilin-
gual processing differences. The inhibition view is also

challenged by evidence from preverbal infants who dem-
onstrate early effects of bilingualism but for whom lan-
guage inhibition is not a plausible explanation (Box 1).

An alternative to inhibition is to consider the demands
imposed by a mixed set of congruent and incongruent
trials: there is always some probability that the next
display may be an incongruent trial. Thus, even on con-
gruent trials the display must be evaluated before the
participant commits to a response. Congruent responses
will typically be faster than incongruent responses, but
individuals with superior attentional control processes
(e.g. bilinguals) will be able to carry out such evaluative
decisions more rapidly and effectively. Therefore, a differ-
ent account of the bilingual advantage is in terms of conflict
monitoring [39,81,82]. Evidence supporting this view
comes from situations in which monitoring demands are
low – if the majority of trials are of one type only [80,81],
the potentially misleading information (spatial position in
the Simon task, flanker items in the flanker paradigm) can
be treated as a valid cue, even if the participant must
respond in the direction opposite to that indicated by the
cue. In such low-monitoring conditions the bilingual ad-
vantage is typically not found. More generally, Hernández,

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Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

Costa, and Humphreys [112] argue for a bilingual advan-
tage in the deployment of attention, enabling them to resist
‘capture’ by irrelevant information; such differences in
attentional control may be the consequence of superior
conflict monitoring. Conflict monitoring and inhibition
are not mutually exclusive: although monitoring is consis-
tent with evidence that pure blocks of congruent trials are
performed equivalently by monolinguals and bilinguals
[102,113], an inhibition account is still required to explain
evidence that pure blocks of incongruent trials are some-
times performed faster by bilinguals, notably by older
adults for whom the task is more effortful [102].

Another problem with a pure inhibition account is that
bilingual advantages are only found with some types of
inhibition. The relevant distinction is captured by the
contrast between the concepts of ‘response inhibition’
and ‘interference suppression’ [75,114]. In response inhi-
bition, a univalent stimulus is associated with a prepotent
response that must be overruled, such as say ‘day’ to a
picture of night or press ‘left’ when the arrow points right.
Bilinguals typically show no advantage in these situations
[75,103]. In interference suppression, a bivalent stimulus
contains two cues, each associated with a different re-
sponse, such as the word ‘red’ written in blue ink, so
attention must be selectively focused on the relevant
cue. Bilinguals typically outperform monolinguals on these
tasks [21]. The hallmark of univalent response inhibition
tasks is that the correct response can be pre-programmed
before the cuing stimulus appears (e.g. ‘if sun appears I’ll
say ‘night’; ‘if the arrow points right I’ll respond left’). On
bivalent tasks, in contrast, the nature of the interfering
information is not revealed until the display appears; for
example, in the Simon task the participant prepares to
respond on the left if the stimulus is green, but cannot
prepare to deal with possible competing information until
the display is shown. Bilinguals are more efficient at
dealing with this online interference, in much the same
way as the picture of a horse presented to a French/English
bilingual would evoke both ‘horse’ and ‘cheval’, one of
which must be suppressed. In a sense, the bilingual must
constantly maintain the set of ‘respond in one language,
suppress the other language’ whenever the possibility of
two languages exists (cf. global inhibition). Further, this
set maintenance must coexist with processing the stimuli
and responses of the language currently utilized in a fluent
and appropriate manner (cf. local inhibition). Thus, lan-
guage use for bilinguals involves interference suppression,
and the online monitoring required in both non-verbal task
switching and language selection is similar.

The suggestion that bilinguals are particularly adept at
maintaining the appropriate one of two (or more) relevant
task goals or attentional sets in working memory has much
in common with the notion of selection of wanted stimuli as
opposed to inhibition of unwanted ones. The net effect is
the same, but by this view the suppression of potentially
interfering information is essentially a consequence of
active selection of the relevant information, rather than
a primary mechanism of direct inhibition. This view is
consistent with that proposed by Colzato and colleagues
[77], who concluded that the bilingual advantage is not due
to the constant exercise of inhibition, but that learning to

246

keep two languages separate leads to an improvement in
selecting goal-relevant information from goal-irrelevant
information.

The sum of the evidence places the bilingual advantage
beyond the explanatory power of a single process, a simple
neural network, or a single executive control component.
Instead, the ongoing experience of monitoring two lan-
guages, in conjunction with the need to monitor context,
speaker, and other environmental cues while inhibiting
attention to the currently unused but active language
modifies how the mind and brain engage in ordinary
conversation for bilinguals. The more effortful any of these
components become, the more likely it is for bilingual
advantages to emerge on non-verbal tasks. However, the
impact of this modification may be seen most clearly on
tasks that bear the closest resemblance to bilingual lan-
guage use, such as task switching. In this case, it is easy to
see how the task of attending to the shape of a stimulus
instead of its color resembles the task of retrieving the
name for an object in French instead of in English. Not
surprisingly, these tasks are typically performed better by
bilinguals than by monolinguals, although the details of
those performances are not yet well understood: some
studies report bilingual advantages on mixing costs indi-
cating set shifting [82,102], whereas others report the
advantage in local switch costs indicating response switch-
ing [76,115]. More generally, it is important to point out
that bilingual advantages are not always found, even on
tasks for which such performance differences would be
expected. Some of the conditions that support the appear-
ance of a bilingual advantage have been discussed, such as
the need for monitoring and difficulty of the conditions, but
others are still unknown. Another factor in determining
performance outcomes is probably the nature or degree of
bilingualism in the participants (Box 2). More details about
the specific tasks and precise language histories of the
bilingual participants may resolve these differences.

Bilingualism and dementia
The finding that bilingualism enhances cognitive control
raises the possibility that lifelong bilingualism protects
against age-related cognitive decline, and may even post-
pone the onset of symptoms of dementia. In this case,
bilingualism may be one of the environmental factors that
contribute to cognitive reserve or brain reserve [116].
Cognitive reserve is the idea that engagement in stimu-
lating physical or mental activity can act to maintain
cognitive functioning in healthy aging and postpone the
onset of symptoms in those suffering from dementia.
These factors include education, occupational status,
higher socio-economic class, and the continuing involve-
ment in physical, intellectual and social activities [117–
119]. If bilingualism contributes to cognitive reserve, then
bilinguals should maintain higher levels of cognitive func-
tioning and cope better with symptoms of dementia than
monolinguals who are otherwise equivalent.

To test this idea, Bialystok, Craik, and Freedman [120]
examined the hospital records of monolingual and bilin-
gual patients who had been diagnosed with various types of
dementia. In spite of being equivalent on a variety of
cognitive and other factors, the bilinguals experienced

Box 2. How bilingual?

Bilingualism is not a categorical experience but experimental

research designs require it be treated as such – participants are

monolingual or bilingual and differences in performance are assessed

for members of the two groups. However, individuals can never be

perfectly monolingual or bilingual: even the most monolingual

people have had some experience with another language, for

example as a school subject or a travel necessity, and all bilinguals

have preferred languages or preferred contexts for each. These

gradations raise three questions about the research results.

The first question is the possibility of a cumulative benefit for

multiple languages. If managing two languages enhances cognitive

control processes, then does further enhancement accrue from the

management of three or more languages, as explicitly proposed by

Diamond [132]? Research by Chertkow et al. [119] on Alzheimer’s

disease and Kavé et al. [123] on normal aging showed better

outcomes for multilinguals than for bilinguals, but there may be

significant differences between multilinguals and bilinguals that do

not exist between bilinguals and monolinguals. As we have

suggested, bilinguals are typically not pre-selected for talent or

interest but multilinguals may often be individuals with high ability

and motivation to learn other languages, factors which may impact

as well on cognitive performance.

The second question is the degree of bilingualism required for

these benefits to emerge. If bilingualism is protective against some

forms of dementia, then middle-aged people will want to know

whether it is too late to learn another language, or whether their

high-school French will count towards cognitive reserve. A related

question concerns the age of acquisition of a second language: is

earlier better? The best answer at present is that early age of

acquisition, overall fluency, frequency of use, levels of literacy and

grammatical accuracy all contribute to the bilingual advantage, with

no single factor being decisive [133] (Gigi Luk, PhD thesis, York

University, Canada, 2008). Increasing bilingualism leads to increas-

ing modification of cognitive outcomes.

Finally, if the benefits of bilingualism are at least partly explained

by the joint activation of two languages, does the similarity of the

two languages matter? Does Spanish–English bilingualism require

more (or less?) attentional control to maintain separation than say

Chinese–English bilingualism? In a study with children who spoke

English plus one of French, Spanish, or Chinese, there was no effect

of the type of bilingualism, and all bilingual children outperformed

monolingual children on tests of executive control [134].

Box 3. Outstanding questions

� Nature of the bilingual advantage: what are the limits and
boundary conditions for the bilingual advantage and why are

bilingual advantages not always found? What is the role of the

standard components of executive control – inhibition, shifting,

and working memory – in bilingual differences in processing? Do

these relations change over the lifespan?

� Cognitive reserve: is the bilingual protection against cognitive
decline similar to other types of cognitive reserve in terms of

mechanism and neural correlates?

� Brain correlates: what changes occur in the frontal lobes? Are
there effects on other brain regions? What is the mechanism for

these experience-dependent changes in frontal networks?

� Psychopathology: what are the neural correlates of the protective
effects for patients with dementia? Does bilingualism have

differential effects on various types of dementia?

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

onset symptoms and were diagnosed approximately 3–4
years later than the monolinguals. Specifically, monolin-
gual patients were diagnosed on average at age 75.4 years
and bilinguals at age 78.6. A replication from a new set of
patients all diagnosed with probable Alzheimer’s disease
(AD) [121] confirmed the results.

Three questions about these results are their reliability,
validity, and causality. For reliability, several studies have
replicated these findings. Chertkow et al. [122] reported
partial support for the original results and showed that
multilinguals were diagnosed with AD later than compa-
rable monolinguals, although a more limited effect was
found when monolinguals were compared with bilinguals.
A similar positive relationship between multilingualism
and high-level cognitive functioning was reported by Kavé
et al. [123] in a study of elderly Israelis. Gollan et al. [124]
reported a study with Spanish–English bilinguals who had
been diagnosed with probable AD and found that a higher
degree of bilingualism was associated with later age of
onset and diagnosis, although only in the less-educated
patients. (See Box 3 for further outstanding questions.)

Second, validity requires demonstrating the specific
relation between the predictor and outcome variables.

Previously, socioeconomic status, cultural differences
and immigration status have been suggested as contribu-
tors to or even causes of the bilingual advantage. However,
in both Toronto studies, educational level and occupational
status favored the monolingual group and immigration
status was ruled out as a contributing factor.

Third, regarding cause and effect, is it possible that
people with ‘good brains’ are both resistant to dementia
and also more likely to learn a second language? This is
unlikely: most people do not become bilingual because they
are bright or have a flair for learning languages, but rather
out of necessity. Supporting this interpretation, a recent
study showed that in a sample of monolingual and bilin-
gual AD patients matched on age, cognitive level, and other
factors, CT scans showed more AD pathology in the brains
of the bilinguals, consistent with the idea that they are
better able to cope with the disease and can function longer
without showing symptoms [125].

Concluding remarks
In the first study reporting the surprising outcome of an
advantage in cognitive and linguistic performance by bi-
lingual children, Peal and Lambert concluded: ‘Intellectu-
ally [the bilingual child’s] experience with two language
systems seems to have left him with a mental flexibility, a
superiority in concept formation, a more diversified set of
mental abilities’ ([9], p. 20). Peal and Lambert did not
explain what they meant by ‘mental flexibility’ but the
description works well to describe the data accumulated in
the 50 years since their original study. Bilinguals do
sometimes have an advantage in inhibition, but they also
have an advantage in selection; bilinguals do sometimes
have an advantage in switching, but they also have an
advantage in sustaining attention; and bilinguals do some-
times have an advantage in working memory, but they also
have an advantage in representation and retrieval. To-
gether, this pattern sounds like ‘mental flexibility’, the
ability to adapt to ongoing changes and process informa-
tion efficiently and adaptively.

It should not be surprising that intense and sustained
experience leaves its mark on our minds and brains – the
functional connections that come from practice are surely
changed by massive experience, and the structural regions
that are recruited for specific activities undoubtedly
change as well through use. These responses to experience

247

Review Trends in Cognitive Sciences April 2012, Vol. 16, No. 4

are precisely what we mean by neuroplasticity. Yet, in the
case of bilingualism, the assumption has long been that
any such effects would be deeply negative: as one influen-
tial educational researcher commented in 1926, ‘This
might be considered evidence that the use of a foreign
language in the home is one of the chief factors in produc-
ing mental retardation as measured by intelligence tests’
([126], p. 393). Almost a century later, and in the face of
substantial evidence to the contrary, there remains resis-
tance to the idea that bilingualism can enhance aspects of
cognitive function. Educational and clinical practitioners
routinely advise parents to ‘simplify’ their children’s lin-
guistic environment when there are signs of academic
struggle, and language professionals prescribe optimal
timetables (and methods) for introducing languages to
children to minimize the inevitable confusion. But such
views are based on fear and anecdote – the weight of
scientific evidence supports the promise of ‘mental flexibil-
ity’. There is still much we do not know about the effect of
bilingualism on the mind, the neural correlates of those
effects, and the causal components of the experience that
lead to them. But it is too late to turn back: it is now clear
that the bilingual mind has been uniquely shaped by
experience.

Acknowledgments
Preparation of this manuscript was supported by grant R01HD052523
from the US National Institutes of Health and grant A2559 from the
Natural Sciences and Engineering Research Council of Canada to E.B.;
grant A8261 from the Natural Sciences and Engineering Research
Council of Canada to F.I.M.C.; and grant MOP57842 from the
Canadian Institutes of Health Research to E.B. and F.I.M.C. We thank
Steven Lovasz for his assistance in preparing the manuscript.

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Bilingualism: consequences for mind and brain

Why bilingualism?
What is different about bilingual minds?
Language processing in bilinguals
Joint activation of languages
Consequences of joint activation
Cognitive networks in bilinguals
Bilingual performance on conflict tasks
Neural correlates of cognitive reorganization
The nature of the bilingual advantage
Bilingualism and dementia
Concluding remarks
Acknowledgments
References

Creative Commons Attribution-Non Commercial 4.0 August 2019 • NEUROLOGY 101

Acquired Language Disorders in Bilinguals

Authors: *Elisa Cargnelutti,1 Barbara Tomasino,1 Franco Fabbro2,3

1. Scientific Institute, IRCCS E. Medea, Dipartimento/Unità Operativa Pasian di Prato,
Udine, Italy

2. Cognitive Neuroscience Laboratory, DILL, University of Udine, Italy
3. PERCRO Perceptual Robotics Laboratory, Scuola Superiore Sant’Anna, Pisa, Italy
*Correspondence to elisa.cargnelutti@lanostrafamiglia.it

Disclosure: The authors have declared no conflicts of interest.

Received: 16.04.19

Accepted: 18.06.19

Keywords: Aphasia, bilingual, language disorders, language impairment.

Citation: EMJ Neurol. 2019;7[1]:101-109.

Abstract

The literature reports an increased number of aphasias involving bilingual people. Dealing with
bilingual aphasia requires particular attention from the diagnostic to the therapeutic phase. In this
review, the authors describe the possible impairment patterns, which could be different between the
two languages and be characterised by specific deficits and sometimes unexpected profiles. The role
of some crucial factors in determining the observed deficits and impairment patterns is illustrated, for
instance age of appropriation and proficiency. An early versus late language appropriation recruits
different brain processes and hence different brain structures. In general, a greater vulnerability is
observed for the late-learned languages, although a high proficiency or use and exposure appear
to prevent language impairment even in the case of late appropriation. The authors also discussed
the role of other intervening factors, such as emotional–motivational aspects, which could explain
unusual profiles. Furthermore, language deficits specific to bilingualism, such as pathological mixing
and switching and translation problems were described. In this respect, the authors underlined the
fundamental involvement of cognitive control mechanisms and of the brain structures associated with
this. Lastly, the clinical practice issues in bilingual aphasia were outlined, underlining the need for a
careful diagnosis. This should take into account the patient’s language history in order to avoid biased
assessments and instead promote the setup of effective intervention programmes.

INTRODUCTION

The cases of bilingual aphasia are increasing
worldwide, as they also reflect the globally
increasing number of individuals speaking more
than two languages (representing more than
half of the population),1,2 who are referred to as
bilinguals, irrespective of the number of known
languages. Bilinguals differentiate one another

under multiple aspects and their clinical language
profiles may differ. In this review, the authors
provide an overview of the different bilingual
aphasia profiles and the factors associated with
these different conditions, providing hints for
their understanding and treatment.

In relation to the different patterns of language
impairment or recovery, Paradis3 proposed, in

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1977, the first structured classification: a) parallel
impairment, in which the languages are similarly
compromised; b) differential impairment, in
which one language is more affected than the
other; c) selective impairment, in which only one
language is affected and the other is spared; d)
blended or mixed impairment, in which there
is interference between the languages and
the patient cannot keep them separated; e)
antagonistic, in which improvement in one
language is associated with an increased
impairment in the other and vice versa;
and f) successive recovery, characterised by
improvement in one language taking place only
after the complete recovery of the other.

These impairment patterns reflect the interplay
between many factors. These include first
the clinical parameters that shape aphasia in
monolinguals as well, such as lesion volume or
patients’ age, but, crucially, also the patients’
language background. To this regard, the age
at which the patients were exposed to the non-
native or second language (L2) is also crucial.4,5
Age of acquisition or appropriation (AoA) is
critical as it influences the way the language is
represented in the brain. Neuroimaging studies
in healthy bilinguals usually take the age of 6 as
the cut-off to differently investigate the brain
networks associated with an early versus late L2
appropriation, because around this age crucial
developmental changes occur in the brain and in
the learning mechanisms. Indeed, up to this age,
language appropriation takes place in the form
of acquisition, meaning an almost unconscious
process supported by implicit mechanisms.
Otherwise, late appropriation is defined in
terms of learning, which instead relies on
explicit processes.6-8

According to authors such as Paradis and
Ullman,6-9 the role of AoA differs based on
the considered language structural domain.
It is particularly crucial for morpho-syntax
and phonology/articulation. Internalisation of
the related processes and, hence, native-like
proficiency can only be achieved with early
acquisition, relying on implicit mechanisms. On
the other hand, lexical knowledge depends more
on the degree of language use and exposure, as
it is supported by explicit memory. Besides AoA,
other factors also influence language mastery
and related brain representation, with the chief
role of proficiency.10 The following paragraphs

illustrate these main factors and relate them to
the impairment patterns.

PATTERNS OF LANGUAGE IMPAIRMENT
IN BILINGUAL APHASIA

Cases of either parallel or differential impairment
are reported in many studies as the sole
conditions, indicating their higher incidence with
respect to the other impairment patterns. For
instance, Fabbro described 20 bilinguals (AoA
up to 7) with left-hemisphere damage, of whom
65% manifested parallel impairment and the
remaining differential impairment. In these,
either the native, first language L1 (15%), or
non-native, L2 (20%), were affected the most.11
According to Paradis, the overall most frequent
condition is parallel impairment, although it is
underrepresented in literature, probably because
it appears less appealing and therefore less
worthy to be reported.6,7

Parallel impairment is frequently observed
between non-native languages (for patients
knowing more than two languages) when these
had similar AoA, in particular when they shared
the same learning modality (e.g., formal
instruction).12 However, parallel impairment was
also observed irrespective of AoA. For instance,
Green et al.13 reported a parallel impairment
between L1 and English, the L2, in patients
having lived in the UK for many years, indicating
the fundamental role of language use and
exposure.13 The authors, however, attributed this
condition to impaired control abilities, which is
discussed further.

Concerning differential impairment, many
patients follow either the so-called Ribot’s rule,
postulating better preservation of L1,14 or the
Pitres’ rule, according to which it is the most
familiar language to be better preserved.15 In
fact, although it is more intuitive to hypothesise
greater resistance to damage for the language
learned first, in many cases L1 was instead the
most affected. This occurred, for instance, when
the patients had a premorbid high level of L2
proficiency and frequency of use, although a
recent systematic review seemed to restrict this
possibility to early bilinguals.16

The patient described by Samar and Akbari17 had
more preserved L2, which she learned at school,
then studied at university and taught there

Creative Commons Attribution-Non Commercial 4.0 August 2019 • NEUROLOGY 103

as a teacher for 18 years. In this case, the high
and deep knowledge of the language together
with its constant use reduced the impairment
severity. In healthy adults, the language networks
appeared highly similar between L1 and L2 when
proficiency is high.10 The learning method,
represented by formal instruction, also had a
possibly relevant role. In fact, as long as the brain
lesion spares the explicit learning system and
therefore the consciously learned meta-linguistic
skills, formal knowledge, which relies on them,
can potentially promote language recovery. This
view is supported by the cases of an apparently
paradoxical profile in which the patients were
impaired in their native language but retained
the use of an only-formally learned language,
including the dead languages, such as Latin.18

Nevertheless, main exposure alone can not
assure the language preservation. Impairment
can indeed occur in cases of L2 learning that
took place recently19 or in adulthood,20 when the
brain is less prone to remodelling and language
brain representation, therefore results can be
less sound, hence more vulnerable to damage.

All the aforementioned language background
factors indeed shape the language brain
representation. Tangible information about the
bilingual patients’ brain networks mainly comes
from intraoperative stimulation studies. In a large-
cohort study, Roux and Trémoulet21 observed
that only two patients displayed solely common
stimulation sites between the two languages,
whereas the majority of them had both common
and language-specific sites. Interestingly,
language-specific sites were observed even
in early bilinguals and, secondly, no additional
cortical sites were found for the less-proficient
language. There were similar results from a
subsequent study on late but proficient bilingual
patients, which further reported ‘L2-restricted
zones’ in the perisylvian cortex, i.e., sites
associated exclusively with L1.22 Although these
findings were limited to the scouting of the
affected region and its surroundings, they show
that even close brain sites may be dedicated
to different languages and that sometimes
neither AoA nor proficiency can predict the
extent of different representation between the
two languages.

The depicted language brain representation
leads us to suppose that a brain lesion, unless
it is small and circumscribed, hardly affects
one language while completely sparing the
other. Nevertheless, a few cases of selective
language impairment have been reported. This
phenomenon was described in patients with
epilepsy, with a selective postictal temporary
loss of either L123,24 or L2.25 This specific type of
impairment may hence have a neurofunctional
rather than a neuroanatomical substrate.
Changes in the normal brain electrical activity
may temporarily inhibit the circuits associated
with a specific language, which is recovered
when the normal brain functioning is restored.
In this vein, selective recovery might also result
from impairment in control functions, which is
illustrated in the following chapter.

The reversible inhibition of one language
characterises another apparently odd condition,
naming the alternating antagonism. This
phenomenon is characterised by phases in
which only one language seems to be accessible,
whereas the other is apparently lost, and usually
takes place in the immediate post-event period.26
This confirms the hypothesis that the impaired
language is not lost, but inhibited, and that when
this inhibition resolves, either spontaneously
or throughout rehabilitation programmes, the
language may recover.

Alternating antagonism is likely to take place
when there is an underlying deficit in the
regulation processes, which caused competition
even between structurally distant languages,
such as Farsi and German, as seen in the patient
described by Nilipour and Ashayeri.27 The patient
also manifested a successive recovery, with
English (L3) recovering only after the complete
recovery of the other two languages.

ROLE OF COGNITIVE CONTROL
IN BILINGUAL APHASIA

Bilingualism indeed entails the need to coordinate
language use to activate the proper language
according to the context, while suppressing the
irrelevant. This entails the constant recruitment of
cognitive control functions and a certain degree
of cognitive flexibility to properly shift from
one language to the other.28 This could be the
reason of the cognitive advantage some studies

NEUROLOGY • August 2019 EMJ EUROPEAN MEDICAL JOURNAL104

observed in bilinguals with respect to
monolinguals, even in presence of aphasia.29

According to the neural convergence hypothesis,30
as bilinguals become more familiar with the new
language, its brain representation converges with
that of the native language. In this perspective,
differences rather rely on the diverse recruitment
of the cognitive control resources. Moreover,
Radman et al.31 observed language improvement
following stroke to be associated with increased
connectivity between language areas and those
devoted to cognitive control.31 However, they
noticed this phenomenon was restricted to the
language that improved the most, therefore
suggesting that, at least in some cases (e.g.,
different AoA or proficiency), differences in the
neural representation between the languages can
actually be present.

Control deficits were observed in both
parallel13,32 and differential or selective language
impairment.33 Recently, many studies aimed to
understand whether possible cognitive control
deficits in bilingual aphasia. Some studies seem
to suggest a language-specific control deficit,32
although problems in general control were also
observed, and the interplay between other
intervening factors, such as task complexity or
lesion site were proposed to modulate the relation
between language and control deficits.13,34

In their recent review on the neuroimaging
of language control, Abutalebi and Green28
recapitulated their previous studies on the topic by
illustrating the specific role of the brain structures
associated with the language control network.
These include both cortical (i.e., prefrontal
cortex, dorsal anterior cingulate cortex/pre-
supplementary motor area, and inferior parietal
cortex, with the involvement of both hemispheres)
and subcortical regions (i.e., left basal ganglia and
thalamus and right cerebellum). These regions are
deputed to specific functions within the language
control process and lesions at their level might
cause different control deficits.

Among these regions, extensive literature has
highlighted the crucial role of the basal ganglia,
and particularly the left (head of the) caudate
and putamen, which are involved in appropriate
language selection. Aglioti and Fabbro35,36
reported the case of a woman who lost her
ability to speak her first language (an Italian
dialect), but surprisingly began to speak Italian,
which she had learned at school but rarely spoke
throughout her life.35,36 She also began to speak
with a strong German accent, a phenomenon
known as foreign accent syndrome and
described even in monolingual patients (Figure 1).

A z=36mm T value T valuez=44mmB

Figure 1: Foreign accent syndrome.

Foreign accent syndrome is a rare acquired motor speech variation, which has been reported in about 60 cases in
literature.37 Patients suddenly exhibit a seemingly ‘strange’ accent and are perceived as having a foreign accent by
listeners of the same speech community. Tomasino et al.38 reported a tumoral patient developing foreign accent
syndrome following a small and circumscribed lesion in the left precentral gyrus. The patient, an Italian native
speaker, developed altered speech rhythm and melody. During pronunciation of words and pseudowords in fMRI
tasks, the patient showed a hyperactivation, compared to the control group, in areas around the pre/postcentral
gyrus corresponding to those involved in phonation (i.e., larynx motor area).
The fMRI cluster related to mouth (A) and tongue (B) movements located behind the patient’s lesion (indicated
by the red circle).

Creative Commons Attribution-Non Commercial 4.0 August 2019 • NEUROLOGY 105

This is a case of paradoxical use of one language
and can be explained in light of the lesion location,
which affected the left basal ganglia,39 and also
stresses the role of the subcortical structures
in implicit memory processes, which normally
support the early acquired languages.

For the role the basal ganglia plays in implicit
memory processes, a lesion at this level is
likely to predominantly affect the mopho-
syntactic processes. This was reported even
for late-learned languages of high proficiency,
for which even these linguistic processes
could have become automated.40 This result
indicates the crucial role proficiency may have
in promoting language representation reshaping
throughout life.

An illustrative case of the association between
lesion site and impaired language was described
by Moretti et al.41 The patient manifested
impairment in the native language following
an infarct in the left caudate nucleus and then,
when a lesion affected the left frontotemporal
cortex, she developed deficits in her late-learned
L2. This supports the predominant cortical
representation of languages learned through
explicit processes, although an opposite trend
was also described.42

OTHER CLINICALLY
RELEVANT FACTORS

Recovery patterns may also be modulated by
factors other than AoA, proficiency, and cognitive
control deficits (see Figure 2 for an overview).
Bilinguals learning a new distant language try
to adopt the same L1 processes, but when these
turn out to be unsuitable, they need to develop
new processes (assimilation-accommodation
processes).43 Evidence is however lacking
regarding the possibly greater impairment in L2
when structurally distant from L1.16

Recorded difficulties reflect the cognitive
demands required to process a given language,
for instance when reading a transparent versus
opaque language. This point is tricky as these
differences might bias the diagnosis between
the languages,44 and therefore call for a language
assessment respectful of language complexity.

Other factors contributing to the definition of a
given impairment pattern include the language
spoken in the environment, namely in the
hospital, in the period immediately following the
clinical event. This factor can also be relevant
from the rehabilitation viewpoint, as lower-than-
expected improvements in the treated language
were attributed to the fact that the patient was
constantly exposed to another language outside
the rehabilitation setting.45

Premorbid parameters
(language history)

AoA Language features
Postmorbid
proficiency

Lesion site and
severity

Premorbid
proficiency

Languistic distance
Postmorbid use/

exposure

Postmorbid use/
exposure

Emotional-motiva-
tional factors

Patient’s age

Learning method
Cognitive control

problems

Rehabilitation

Postmorbid parametersClinical parameters Other factors

Figure 2: Overview of the factors contributing to the different language recovery patterns.

AoA: age of acquisition or appropriation.

NEUROLOGY • August 2019 EMJ EUROPEAN MEDICAL JOURNAL106

Finally, even the affective factors can assume a
fundamental role. Emotionally relevant episodes
may induce the release of the apparently lost
language46 and the willingness to recover a given
language may actually prompt its improvement.47

SPECIFIC LANGUAGE DEFICITS IN
BILINGUAL APHASIA

Differently from monolinguals, bilingual patients
may develop deficits characterising specifically
the bilingual condition and concerning the
reciprocal use of the two languages. These
symptoms include mixing (i.e., recourse of words
or other elements of one language during the
use of the other), switching (e.g., shift from
one language to the other), and problems
in translation.

Frequently, these events arise from lesions in
the mentioned areas involved in regulating the
proper language use,48,49 with greater interference
frequently observed between two structurally
close languages.19,50 Fabbro et al.51 described
the case of a patient with a glioma in the left
prefrontal and cingulate cortices who involuntary
switched to his native language, even talking to
people he knew could not understand it, indicating
the inability to inhibit the process.

Lesions in other areas were observed to
pathologically induce or prevent language
switching and include the inferior parietal lobe52
and the fronto-temporal cortex.53 Interestingly,
switching was observed during direct
electrostimulation of specific brain sites (Figure
3), including the white-matter tracts connecting
control and language-specific brain areas.56

In some other cases, these phenomena reflect
language impairment, as they occurred to
compensate for anomia or other difficulties in the
more impaired language.57,58 This can also be the
case of translation deficits, which often reflect
the general impairment in a specific language,
with greater difficulty in translating from better
preserved to more impaired languages than
vice versa. Sometimes, this language deficit
occurs selectively, despite spared ability in
naming59 or in recognising translation equivalents
across the languages.60 In other cases, in which
naming abilities were impaired, translation
processes were preserved, and further employed
to recover word finding difficulties through
translation from the preserved languages, therefore
preventing switching.49

However, some patients were observed to
paradoxically translate to the most affected
language while unable to translate to the spared
language,61 for instance when antagonistic
recovery occurred.26 Sometimes, the patients
instead manifest the compulsive tendency to

Figure 3: Switching from L2 to L1.

In neurosurgical patients, Penfield W and Roberts L54 largely documented language switching during electro-
cortical stimulation mapping as an automatic mechanism that turns off one language when the other language is
on. Tomasino et al.55 described involuntary language switching from L2 (Italian) to L1 (Serbian) evoked by electro-
stimulation in the left superior temporal gyrus/supramarginal gyrus during awake brain surgery. The language
switching site belonged to an fMRI cluster in the area Stp (in the planum temporale) which has a role in phonological
processing and was found to activate for both L1 and L2 during language tasks.
The language switching site (MN1 coordinaltes: x=-61, y=-30, z=18)

Creative Commons Attribution-Non Commercial 4.0 August 2019 • NEUROLOGY 107

translate from one language to the other, while not
being able to prevent this automatic behaviour.39

ISSUES IN BILINGUAL APHASIA

Dealing with bilingual aphasia requires specific
precautions from the diagnostic to the
therapeutic phase. Firstly, for a proper diagnosis,
it is fundamental to take into account the level
of premorbid language proficiency, which was
observed to be one of the most important factors
in predicting the postmorbid level of deficit.62
Hence, it is fundamental to first thoroughly inspect
the language history (e.g., AoA, proficiency,
frequency, and context of use) by means of
structured questionnaires.

Secondly, clinical assessment should ideally
be performed in all the languages the patient
knows, even though, especially for immigrated
people, clinicians may not master the patient’s
L1. When testing the different languages, it is also
fundamental to take into account the structural
differences between them. To this aim, Paradis
and Libben developed the Bilingual Aphasia
Test (BAT), now available in >70 languages, with
items for each language matched in complexity
and selected for their cultural adequacy.63 The
battery is structured in three parts: the first
inspecting the language history, the second
making a comprehensive assessment of each
language skills, and the last addressing specific
language pairs, offering an understanding
of which language was affected the most. A
proper diagnosis is fundamental for setting the
rehabilitation programme. Ideally, each impaired
language should be treated. When this is not
possible, therapists should train the language
that could have more beneficial effects on the
untreated language, therefore promoting cross-
linguistic transfer. Although not univocally, many
studies have observed that treatments focussing
on the weaker language, meaning a non-
native language64 or, in the case of comparable
AoA, a lower-proficiency language65 are more
likely to boost improvements in the untreated
language.62,63 With regard to naming training,
this trend can be explained in light of the revised
hierarchical model by Kroll and Stewart,66
according to which L1 words are tightly linked
to their correspondent meaning, whereas L2
word semantic access occurs via translation
to L1. Consequently, semantic access after L2
training likely takes place by passing through
the L1 lexicon, which recovers in turn. In the case

of difficulty in properly regulating the language
use, rehabilitating general cognitive functions is
recommended first.67

Gil and Goral,68 however, qualitatively observed
beneficial transfer effects following treatment in
each language, in spite of the structural distance
between them (i.e., Russian and Hebrew, for which
transfer was poor only in/for writing, which differs
substantially between them). However, they
tested the patient in the subacute phase, when
spontaneous recovery was also taking place. The
majority of the reported studies, however, took
charge of the patients in the chronic phase and
documented positive treatment effects as well.
Language skill improvement and associated brain
reorganisation were observed to occur just 10
days after intensive training, indicating the high
brain plasticity potential even many months
post-onset.69

According to Kiran et al.,70 all the parameters that
have been described, such as AoA, language use,
and proficiency before and after the clinical event,
are relevant for the prediction of the recovery
profile following treatment, although their
interplay and the intervention of additional
factors undermines an accurate prediction. In
some instances, lack of transfer can be attributed
to factors other than the treated language.
These can include the choice of inappropriate
rehabilitation strategies,71 the impossibility
to practice the treated language outside
the rehabilitation setting,45 the fact that the
unimproved language had already reached
its highest recovery level.72 Lastly, some partly
unexpected improvements might be attributed
to the willingness to recover a given language,
highlighting the emotional valence the languages
can take on.47

CONCLUSION

In conclusion, although it is difficult in clinical
practice to concretely take account of the
bilingual patients’ languages, some attempts
should be made to achieve an accurate diagnosis
and guarantee the most effective possible
therapeutic intervention, as impairments in a
given language can have relevant consequences
for the patients’ life on social, affective, and
working levels.

NEUROLOGY • August 2019 EMJ EUROPEAN MEDICAL JOURNAL108

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