ORIGINAL REPORTBilingual Children: Cross-sectional Relationsof Psychiatric Syndrome Severity and DualLanguage ProficiencyClaudio O. Toppelberg, MD, Alfonso Nieto-Casta˜non, PhD, and Stuart T. Hauser, MD, PhDThe severity of child psychiatric disorders is commonly associated with child language delays. How-ever, the characteristics of these associations in the fast-growing population of bilingual childrenremain unknown. To begin to address this gap, we studied a unique sample of Spanish-Englishbilingual children with significant parent-reported psychopathology (n = 29), focusing on theirlanguage proficiencies and psychiatric severity using the Child Behavior Check List. We presentcross-sectional analyses of associations of general and specific language proficiency in Spanish andEnglish with the severity of specific psychiatric syndromes. We found Spanish language-proficiencyscores to have negative correlations with a wide range of psychiatric symptoms, particularlyexternalizing (i.e., delinquency and aggression) symptoms (r =−.38 to −.61, p ≤ .05). Englishscores were similarly associated. Dual language tests covering multiple specific language dimensionsexplained a large proportion (51%) of overall variance in aggression symptoms and also importantproportions (40%) of total and attentional symptoms. While children’s proficiency levels in bothSpanish and English showed similar associations with the symptom severity measures (explainingclose to 20% of the symptom variance; rsp=−.44, p < .01), these proficiency levels explainnonconverging variance in children’s symptomatology. The findings suggest that clinical evaluationof language functioning is often needed in such populations and that it should be comprehensiveand include both languages. Such thorough evaluation of bilingual children suffering from psy-chopathology will help us to precisely identify (1) language deficits, (2) specific relations of thesedeficits to the child’s psychopathology, (3) differential implications of communication at home (e.g.,in Spanish) and at school (e.g., in English) for clinical presentation and the child’s competence inthose differing contexts, and (4) language of choice for therapy, evaluation, and educational services.The findings are discussed in the context of clinical and conceptual implications and future researchneeds. (HARV REV PSYCHIATRY 2006;14:15–29.)Keywords: bilingualism, child, language development disorders, mental health, minorities,psychopathologyFrom the Department of Psychiatry, Harvard Medical School(Drs. Toppelberg and Hauser); Judge Baker Children’s Center(Drs. Toppelberg, Nieto-Casta ˜non, and Hauser) and Children’s Hos-pital Boston (Drs. Toppelberg and Hauser), Boston, MA; ResearchLaboratory of Electronics, Massachusetts Institute of Technology (Dr.Nieto-Casta ˜non); and Cognitive and Neural Systems Department,Boston University (Dr. Nieto-Casta ˜non).Supported primarily by National Institute of Mental Health grantnos. K01 MH01947-01A2, MH19126, and MH16259, and grant sup-plement to R01 MH44934-07A1; a Children’s Studies at HarvardResearch Award; an American Academy of Child and AdolescentPsychiatry Eli Lilly Award; and a Harvard Department of Psychia-try Livingston Award.Original manuscript received 19 January 2005, accepted for publi-cation subject to revision 23 June 2005; revised manuscript received19 July 2005.Correspondence: Claudio Toppelberg, MD, Judge Baker Children’sCenter, Harvard Medical School, 53 Parker Hill Ave., Boston, MA02120-3225. Email: [email protected]c2006 President and Fellows of Harvard CollegeDOI: 10.1080/106732205005196981516 Toppelberg et al.Harv Rev PsychiatryJanuary/February 2006INTRODUCTIONLanguage Proficiency and PsychopathologyEpidemiological and clinic-based empirical research has doc-umented relations between language deficits and children’spsychiatric symptoms.1–3It is now well established that lowlanguage skills are associated with poor functional adap-tations and specific symptoms, as well as diagnoses.1,4,5Inparticular, poor language skills predict poor social skills,4and language-impaired children are often poorly socialized6and poorly accepted by their peers.7In terms of psychi-atric syndromes, language deficits predict language-basedlearning disorders (e.g., dyslexia), depressive and anxiety(“internalizing”) disorders, and greater severity and preva-lence of attention deficit/ hyperactivity and other disrup-tive behavior (“externalizing”) disorders.1,3,4Receptive lan-guage deficits (i.e., deficits in word or sentence comprehen-sion) are the strongest predictors of psychopathology, partic-ularly of aggressive, hyperactive, and antisocial outcomes.3,4Receptive language deficits are more likely to be over-looked than the more obvious, often coexisting, expres-sive deficits (i.e., deficits in the developmentally appropri-ate production or retrieval of sentences and words). Lan-guage deficits and disorders are very common among psy-chiatrically referred children, with estimated prevalencesranging from 30 to 75%.1Suggested causes for the con-nection between psychiatric and language deficits includeshortcomings in social competence, difficulties in language-mediated emotional and behavioral regulation, and the pres-ence common neurodevelopmental and contextual risk fac-tors. When language deficits and disorders go undetected—a frequent occurrence—they are associated with more se-vere psychopathology and inadequate services later on inthe school trajectory.8Consequently, researchers in thisarea have strongly advocated for the early detection oflanguage deficits. The preceding studies clearly documentrelations between psychiatric and linguistic deficits. Yetvirtually all of the language-psychopathology research ex-cludes bilingual children or those speaking languages otherthan English.3To our knowledge, the only exceptions area study of monolingual Dutch-speaking children9and ourprior study of bilingual children10—see below.It is extremely important to learn about relationsbetween psychiatric and linguistic deficits in bilingualchildren—those who communicate in two languages. It isalready clear that childhood bilingualism is common andbecoming more prevalent. As we witness the largest wave ofchild immigration in American history,11current surveys es-timate that ten million American children—19% of the U.S.child population, mostly U.S.-born children of immigrantparents—have English as