Should All Deaf Children Learn Sign Language?

Letter to the Editor,

As a parent of deaf children, a teacher-trainer in deaf education, a researcher, and an administrator at a school for the deaf, I find the opinions and research cited in Should All Deaf Children Learn Sign Language, (Mellon, Niparko, Rathmann, Mathur, Humphries, Napoli, Handley, Scambler, and Lantos, 2015) to be confusing because the term "sign language" is undefined, some of the citations are outdated, and important research is unutilized. A longer version of this letter is available from the author that gives multiple examples. At Northwest School for Deaf and Hard of Hearing Children (NWSDHH), where I work, speech and Signing Exact English (S.E.E.) is used whenever either adults or children, preschool through 8th grade, communicate with one another. I was motivated to write a letter to the editor because the research and practice regarding S.E.E. are counter to some of the points made in the article by Mellon et al. (2015) (See for example, Nielsen, Luetke & Stryker, 2011). I have used "The Case" and the comments in the section by Mellon and Niparko to highlight exceptions to some comments made by each of the authors. The Case. Mellon et al. (2015) suggested that families need to choose either ASL or Spoken Language (oral-aural). In the Seattle area families one of three methods of communication; those who opt for the use of simultaneous spoken language, listening, and S.E.E. can receive instruction during home visits, weekly classes, or at an annual intensive workshop, all sponsored by the largest implant center in the state NWSDHH teaches SEE to those who speak Spanish in the Spanish-Speaking Families (S.E.E.) Program. Response to comments of Mellon and Niparko. Research has documented that "a CI can enable strong, spoken language" in environments other than "intensive auditory-oral exposure in extended, salient and child-initiated interactions" (p. 2). Intelligible speech can be developed as well when S.E.E. is paired simultaneously with spoken English, and listening, speech, and English grammar are valued, assessed, and facilitated by teachers of the deaf who use data to guide lessons (McLean, Nielsen, Stryker, & Luetke, 2014). Research has justified this approach. For example, Guo, Spencer & Tomblin (2013) noted that children with CIs receive a "degraded electrical signal" (p. 188). They found that at four- to-five years post implantation, children continued to omit tense markers (-ed, -s, etc.) and were more linguistically delayed as they grew older, a time when knowledge of more and more bound morphemes are necessary to understand the vocabulary of texts (pp. 202-203; Guo et al 2013; McLean et al, 2014). One explanation for this difficulty is that "these morphemes in English are acoustically insalient...have relatively shorter duration and/or weaker energy as compared to surrounding content words" (p. 187).

I hope this partial letter to the editor will assist pediatricians who "need to keep up-to-date on the latest research, translate that research into language that parents can understand, and help them make choices that are best for their child, their family, and themselves" (p. 5). Sincerely, Barbara Luetke Ph.D. [email protected]

References Guo, L.Y., Spencer, P., & Tomblin, B. (2013). Acquisition of tense marking in English-speaking children with cochlear implants: A longitudinal study. Journal of Deaf Studies and Deaf Education, 18(2), 187 -205. doi:10.1093/deafed/ens069 McLean, M., Nielsen, D. C., Stryker, D., & Luetke, B. (Winter, 2014). Characteristics of students who read on grade level: What can teachers influence? The Canadian Nielsen, D. C., Luetke, B., & Stryker, D. (2011). The importance of morphemic awareness to reading achievement and the potential of signing morphemes to supporting reading development. Journal of Deaf Studies and Deaf Education, 16(3), 275-288. doi:10.1093/deafed/enq063

Conflict of Interest:

None declared

I am a speech-language pathologist with 18 years of experience. I am also fluent in American Sign Language. It is my experience that deaf children with cochlear implants learn English much faster when sign language is used as the mode of instruction. I believe deaf children need to be bilingual to be able to maximize their potential for employment and social interaction. The key is applying their oral language to daily situations in order to make it functional and fluent. To restrict a child to oral language only is to limit their opportunities to develop relationships in the deaf community. This is unfortunate because they will find kindred interests with other deaf persons. A hearing person cannot fully understand the challenges of deafness in a hearing world, so the support they give to each other is extremely important.

Conflict of Interest:

None declared

The question of how best to raise and educate deaf children has been a vexed question for more than a century. While everyone recognizes the remarkable benefits of cochlear implants (CIs), there is considerable debate about whether children who receive a cochlear implant should continue to learn sign language (SL).

Those who favor an exclusive focus on listening and spoken language (LSL) suggest that the use of SL leads to worse auditory and spoken language skills and thus defeats the purpose of the cochlear implant. Those who favor a bilingual approach - that is, the use of SL in addition to LSL - argue that all deaf children can become fluent in SL without any detriment to their skills in LSL. The debate thus turns on two distinct empirical questions. First, do children who receive a CI and who then focus solely on LSL predictably have outcomes that are sufficiently good so that they will never need SL in order to learn and communicate? Second, does continued use of SL lead to worse outcomes?

The questions are difficult to answer because many studies have limited sample sizes, lack of matched controls, and other methodological problems. Still, it is clear that many children who receive bilateral CIs before the age of 2 can do well in school. It is also clear that many children do not achieve normal speech perception levels and experience severe difficulties in challenging listening tasks.

There is very little data about the second question. For example, in arguing that continued use of SL is detrimental, Sugar and Goldenberg cite a study that was presented as an abstract in 2009 but has never been published.

A big problem with assessing outcomes for deaf children who learn SL along with auditory-verbal communication is that, for most of those children, neither their parents nor their educators are fluent in SL. In one study in which such children were raised by deaf parents who were fluent in SL, the children learned both LSL and SL well. But like other studies, it is very small.

Based on the data, then, it is hard to know with certainty whether or not learning SL in addition to LSL will lead to better, similar, or worse outcomes. And therein lies the source of all the disagreement.

The problem can thus be summarized straightforwardly. If one does not believe that concurrent SL impairs long-term outcomes for LSL, then the choice is clear. Learn both languages. If one believes that SL is harmful, then there is a more complex set of probabilities to consider. Do you choose the exclusively auditory route, hoping that, by doing so, the child will have the best chance to develop age-appropriate school skills, but knowing that many children who go that route do not attain those skills. Or, do you choose the bilingual route, thereby guaranteeing that the child will be fluent in at least one language but taking the risk that it could impair the child's outcomes in LSL? There clearly can be no single best right answer to these questions.

References

Benito S. Alexander Graham Bell and the Deaf community: A troubled history

http://www.rootedinrights.org/alexander-graham-bell-and-the-deaf- community-a-troubled-history/

NAD Position Statement on Cochlear Implants 2000 http://nad.org/issues/technology/assistive-listening/cochlear-implants

Napoli DJ, Mellon NK, Niparko JK, et al. Should All Deaf Children Learn Sign Language? Pediatrics. 2015 136:170-6.

Wieringen A, Wouters, J. What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills? Hearing Research 2015; 322: 171-9.

Davidson K, Lillo-Martin D, Pichler DC. Spoken English Language Development Among Native Signing Children With Cochlear Implants. J Deaf Stud Deaf Educ 2014; 19: 238-50.

Conflict of Interest:

none

I agree with Pediatrics' article in Ethics Rounds - Should All Deaf Children Learn Sign Language. It is very beneficial for Deaf children to learn American Sign Language. American Sign Language has been in use since April 15, 1817. When Alexander Graham Bell and his group decided oralism a.k.a. Listening and Spoken Language is the best way, they changed rules on September 11, 1880. There was no Deaf representation at the infamous Milan Conference. They did terminate Deaf teachers and replaced them with hearing people who did not know American Sign Language. They have been oppressing Deaf people's functioning lifestyle and refused to incorporate sign language in classrooms. Deaf people have been and are still successful in our lives for the last 198 years. We have achieved ourselves as doctors, lawyers, scientists, teachers, etc. in many fields. We love to use our American Sign Language. It is a natural language and it is the third most use language in the North America. The truth remains that American Sign Language is a best option for Deaf people. As George Veditz stated in 1913, "As long as we have deaf people on earth we will have signs, and as long as we have our films we can preserve our beautiful sign language in its original purity." Deaf people's mental health fare better using ASL than using Listening & Spoken Language. Sincerely, Paul Kiel American Sign Language Instructor/Deaf Culture & History Lecturer Quincy University Quincy, IL

Conflict of Interest:

None declared

By Laurie Hanin

The July 2015 article, "Ethics Rounds: Should All Deaf Children Learn Sign Language," concludes that the benefits of learning sign language clearly outweigh the risks and that this approach seems clearly preferable to an approach that focuses solely on oral communication., and all deaf children should learn sign language.

As a professional in the field for over 30 years and speaking as the Executive Director of the Center for Hearing and Communication (CHC) in NYC, I do not believe that there is one way for "all" deaf children to learn language or to be educated. At CHC, we provide a wide range of services to people with all degrees of hearing loss regardless of mode of communication. That said, our habilitation program for children who are deaf or hard of hearing is an auditory-oral program with the goal of having the children attend a mainstream educational program, typically beginning in the preschool years. While we recognize that this approach may not be the right choice for every child, with the advent of universal newborn hearing screening, technical advances in amplification (including early bilateral cochlear implantation), and access to early intervention, this is a realistic option for more children than ever before.

At the Center for Hearing and Communication, it is no longer unusual for us to begin working with infants as young as four weeks of age, immediately providing amplification and beginning a habilitation program with the infant, family, and other caregivers. It would be an extremely rare case where a trial of hearing aids was not medically indicated, and with current amplification technology, some degree of hearing aid benefit is always provided. It is becoming the "norm" for infants to receive a cochlear implant, if not two implants, by the age of 7 months. As a result of this early intervention, the children we see are achieving age appropriate linguistic and cognitive milestones at very young ages.

It is our hope that when pediatricians find themselves in a position to counsel families of newly diagnosed deaf children they recognize, as we do, that every family and child is unique and every recommendation must be individualized. We also hope that in this ever-changing field, they recognize that the outcomes possible today for deaf children learning spoken language far exceed those that are seen in published research of just a few short years ago. The controversy over whether or not sign language should be incorporated into a deaf child's communication system is almost 200 years old. The field of early childhood deafness and the opportunities for management has dramatically changed even within the last five years and how we discuss this controversy must change as well.

Conflict of Interest:

None declared

Much of "Ethics Rounds: Should All Deaf Children Learn Sign Language" in the July 2015 issue of Pediatrics treats the decision on the use of sign language for a deaf child as unambiguous. Although most of the authors embraced the use of sign in conjunction with a cochlear implant (CI), research on this topic is not definitive. The approach of most clinicians and educators who work in the field emphasizes spoken language unless the child has other complicating issues that require visual support. Notably, as Mellon and Niparko point out in their contribution to this discussion, spoken language outcomes with cochlear implantation are predicted by the level of spoken language proficiency that is achieved prior to implantation. Speech immersion is critical throughout the process. The Pediatrics panel's "conclusion" that sign as a supplement to spoken language for deaf children is "clearly preferable" is not supported in the literature cited by Mellon and Niparko, nor in the wider literature, nor in practice, and points up bias in the stated conclusion.

American Cochlear Implant Alliance members are clinicians from across the care continuum including surgeons, audiologists, therapists and educators working with children and families. Two factors have repeatedly been shown to affect language outcomes: (1) child's age at the time of CI with the critical window being prior to 18 months of age (1,2,3) and (2) extent of enriching parental engagement with the child in learning and developing language (4). . Numerous dynamics that may affect the child's development are ongoing. Parents must learn about use of technology and how to support a deaf child who is learning to listen and speak--the goal of most families choosing CI. Learning a second language, while a positive goal, may not be practical. Research shows that when a family is not fluent and ASL is given emphasis, the child's language and reading levels fall behind because the family cannot provide the needed environment to foster an accelerated trajectory of language learning. For a child in a low SES family or single parent family or both, the burden of becoming fluent in sign can be overwhelming. The sign language decision is very personal and deserves thoughtful consideration with the CI team and family. There are no data supporting a single right approach.

These issues are unlikely to fall within most pediatricians' training. When advising families, pediatricians can and should emphasize two fundamentals that are supported by research-- * early CI results in the best spoken language outcomes and, * family-centered intervention by personnel with specialized skills supporting spoken language development are indicated at an early age.

A child with severe to profound hearing loss should be referred to a CI center by six months of age so that specialized clinicians can help the family to understand their options, including cochlear implantation. Too often families make their initial visit to a CI clinic after a child has lost valuable time, after the critical neurobiological window of opportunity to optimize auditory language outcomes has closed.

References

1. Niparko JK, Tobey EA, Thal DJ, Eisenberg LS, Wang NY, Quittner AL, Fink NE. Spoken language development in children following cochlear implantation. Childhood Development After Cochlear Implantation. Investigative Team, JAMA 2010 April 21; 303(15):1498-506.

2. Svirsky MA, Teoh SW, Neuburger H. Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol Neurotol. 2004 Jul-Aug;9(4):224- 33.

3. Geers AE, Nicholas JG. Enduring advantages of early cochlear implantation for spoken language development. J Speech Lang Hear Res. 2013 Apr;56(2):643-55. doi: 10.1044/1092-4388(2012/11-0347).

4. Quittner AL, Cruz I, Barker DH, Tobey E, Eisenberg LS, Niparko JK. Effects of maternal sensitivity and cognitive and linguistic stimulation on cochlear implant language development over four years. Childhood Development After Cochlear Implantation Investigative Team. J Pediatr, 2013 Feb:162(2):343-8.e3

Conflict of Interest:

None declared

The National Association of the Deaf (NAD) applauds you for your July 2015 article, "Ethics Rounds: Should All Deaf Children Learn Sign Language?" The article addresses an ongoing debate in the education of deaf children, and rightfully examines the evidence regarding delayed language and cognitive development in deaf children.

A majority of families with deaf children are persuaded by misguided professionals to pursue listening and speaking only and exclude the use of American Sign Language (ASL), and the evidence shows that many of these children do not acquire language and cognitive development at age appropriate levels. Even with cochlear implants, the most advanced listening technology, the best estimate is that only 40% of children with implants get some benefit for language learning from the technology (Humphries et al. 2012). And in that 40%, many show effects of early language deprivation.

Today, we have studies that show the effects of language deprivation at this early age. These effects are not shown when children learn ASL from birth. These studies are readily available to those who would deprive children of learning a sign language in early childhood, and we encourage an opening of minds to look closely at what newer research of the last 10-15 years has revealed (Mayberry 1994). In the Ethics Rounds discussion, most of the participants agree that emerging research shows that American Sign Language reduces the risk that deaf children will have delayed language and cognitive development.

Those who attempt to portray the choice as being between speech and listening or signing are perpetuating a myth. This is not the choice. Many families choose both, and, in fact, there are many research studies that show a strong correlation between fluency in ASL and reading ability in English (Mayberry, del Giudice, and Lieberman 2011; Padden and Ramsey 1998; Prinz and Strong 1998). Both languages are needed to reduce the risk of harm to deaf children when many are unable to fully acquire spoken language through speech and listening alone.

As an organization comprised primarily of deaf and hard of hearing adults who have experienced every kind of educational methodology, we are united in expressing our support for the use of both ASL and English for all deaf children. We also want to affirm our love and respect for our parents, and communicate with them fully as a family. With a solid education in both ASL and English, we are not segregated from society but are fully empowered to engage as equal partners. The NAD has many parents and professionals as our members and allies, and we welcome everyone who supports our mission of preserving, protecting, and promoting the civil, human and linguistic rights of deaf and hard of hearing people in the United States.

Thank you again for this "Ethics Rounds."

Humphries, T., P. Kushalnagar, G. Mathur, D. Napoli, C. Padden, C. Rathman, and S. Smith. 2012. "Cochlear implants and the right to language: ethical considerations, the ideal situation, and practical measures toward reaching the ideal." In Cochlear Implants Research Updates, edited by C. Umat and R.A. Tange, 193-212. InTech.

Mayberry, R., A.A. del Giudice, and A. Lieberman. 2011. "Reading achievement in relation to phoological coding and awareness in deaf readers: A meta-analysis " Journal of Deaf Studies and Deaf Education no. 16 (2):164-188.

Mayberry, Rachel I. 1994. "The importance of childhood to language acquisition: Evidence from American Sign Language." In The development of speech perception: The transition from speech sounds to spoken words., edited by Judith C. Goodman, Howard C. Nusbaum and et al., 57-90. Cambridge, MA, USA: The Mit Press.

Padden, C., and C. Ramsey. 1998. "Reading ability in signing deaf children." Topics in Language Disorders no. 18 (4):30-46.

Prinz, P, and M. Strong. 1998. "ASL proficiency and English literacy within a bilingual deaf education model of instruction." Topics in Language Disorders no. 18:47-60.

Conflict of Interest:

None declared

The July 2015 article, "Ethics Rounds: Should All Deaf Children Learn Sign Language," questions whether parents of a deaf child should communicate with their child via American Sign Language (ASL) or listening and spoken language (LSL) and seems to suggest that use of ASL outweighs an approach that focuses solely on LSL. The Alexander Graham Bell Association for the Deaf and Hard of Hearing respectfully disagrees. AG Bell fully supports families being made "aware of all communication options in an unbiased manner,"1 including ASL, LSL and other methods. However, pediatricians should consider the evidence and the outcomes of children of such options. The article should have presented a panel of more balanced and accurate responses.

More than 88 percent of families choose a LSL outcome for their deaf child (personal communication, 2015). AG Bell supports these families by advocating for LSL through evidence-based practices that focus on achieving successful outcomes through the use of auditory teaching and appropriate technologies such as hearing aids and CIs.2 The evolution of CI technology demonstrates that CIs received at an early age are effective in providing a deaf child the ability to hear and speak.3

Studies show that children who follow an auditory-verbal (A-V) communication approach (solely utilizing LSL, and not ASL), demonstrate better LSL skills than do children who follow a total communication approach utilizing both LSL and ASL.4 Goldberg and colleagues studied 23 patients at the Cleveland Clinic's Hearing Implant Program who receive A-V therapy and, based on standardized tests, they demonstrated expressive and receptive language test scores with the majority at or above their "typical" hearing peers.5

In discussing options with parents, physicians should consider current and emerging evidence. While bilingualism may be helpful to hearing children and occasionally to deaf children who are unable to fully achieve LSL, a young CI child (already playing "catch up" to hearing peers) requires constant and consistent auditory teaching. Immersion in spoken language is critical to the LSL success of a CI child, as is teaching the child to communicate with spoken language. The window for a deaf child to acquire LSL is much shorter than the window in which ASL can be acquired.

Deaf children today frequently communicate quite well with LSL alone, and the number of children who have a need of ASL to communicate has decreased dramatically. When today's parents are told that these children should learn ASL as part of a Deaf culture, they increasingly respond that their children actually are part of a hearing culture - that of their families, friends and the world at large. Children today have unprecedented opportunities to develop listening and spoken language, thanks to newborn screening, early identification and intervention, and tremendous technological advances which were unavailable to past generations. Clearly, what it means to be "deaf" truly has changed.

Meredith K Sugar, 1 Donald M Goldberg, 2. 1. President, Alexander Graham Bell Association for the Deaf and Hard of Hearing. 2. Professor, College of Wooster, Ohio; Listening and Spoken Language Specialist, Cleveland Clinic's Hearing Implant Program.

References

1. Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007; 120(4): 989-921. doi: 10.1542/peds.2007-2333

2. Alexander Graham Bell Association for the Deaf and Hard of Hearing. 2008. Position Statement: Spoken Language.

3. Niparko JK, Tobey EA, Thal DJ, Eisenberg LS, Wang N-Y, Quittner A, Fink, NE. Spoken language development following cochlear implantation. JAMA. 2010; 303(15): 1498-1506. doi:10.1001/jama.2010.451

4. Thomas E, Heavner K, Zwolan, T. Communication mode and speech and language outcomes of young cochlear implant recipients. Paper presented at 12th Symposium on Cochlear Implants in Children, Seattle, WA. 2009.

5. Goldberg D, Weber P, Mantz R. Auditory functioning and spoken language abilities of children with cochlear implants: Outcomes. Paper presented at the 13th Symposium on Cochlear Implants in Children, Chicago, IL. 2011.

Conflict of Interest:

None declared