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Clinical Pediatrics
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© The Author(s) 2015
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DOI: 10.1177/0009922815616891
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Commentary
The principle of respect for autonomy in modern medi-
cal ethics1 leads doctors to avoid persuasion and aim for
neutrality when discussing language choices regarding
deaf infants. However, at times persuasion to overcome
biases is necessary and ethically mandatory.2
Many parents and health professionals have faith in the
ability of cochlear implants (CIs) to allow deaf children to
“hear” and achieve normal language and speech develop-
ment. While it is good to encourage parents’ hope for their
children’s future, to avoid bias, medical professionals
must acknowledge the reality that CIs do not replace nor-
mal hearing. As of 2006, 80% of deaf infants in Northern
Europe were receiving CIs,3 and as of December 2010,
roughly 40% worldwide.4 Parents need to know that CI
may not guarantee their child’s language acquisition.
While a CI is usually given only to a child who will not
benefit from a hearing aid, it is important to recognize that
CIs are not “super hearing aids”; even hospitals that per-
form CI surgery make statements such as: “For most
patients, a cochlear implant will not work as well as a
hearing aid” 5 and studies support that statement.6 That’s
because a hearing aid (HA) simply amplifies sound,
whereas with CIs sound is transformed into electrical
impulses delivered directly to the cochlear nerve. The
CI-child must undergo long-term extensive training to
interpret those electrical impulses.7 Unpredictable indi-
vidual variation in outcomes is pervasive even with great
effort and dedication from caregivers and the deaf child8;
some deaf children receive little to no auditory benefit
from CIs in acquiring language.9
The neuronal plasticity of the brain with respect to lan-
guage acquisition is maximal before the age of 3 years10; if
a child is not fluent in a language by the age of 5 years, that
child may never achieve full fluency in any language.11 At
the same time during this critical period, the increase in
synaptic density occurs earlier and more rapidly in the
occipital cortex than in the auditory12; so the deaf infant’s
brain is primed for visual input. Sign languages provide
this visual input; access to signing can ensure language
acquisition for deaf children and avoid cognitive deficits
associated with linguistic deprivation.13-16 The deaf child
who signs well does better academically than the deaf child
who doesn’t, regardless of all other factors,17 and most
attribute this to the fact that the signing deaf child is not at
a linguistic disadvantage. Given evidence such as this, a
recent panel of specialists concluded that all children born
deaf should be taught a sign language immediately.18
We are a team of specialists in education studies, lin-
guistics, pediatric medicine, and developmental psy-
chology; our work focuses on deaf individuals. In order
to help the practicing pediatrician, we offer here
responses to common family questions. Our responses
respect families’ autonomy while bearing in mind the
difficulty that many parents have coming to terms with
children who are different. The evidence-based informa-
tion related to deaf children’s language and speech
development here should help enable parents to better
be involved in making the relevant decisions.19,20 Our
intention is for the advice below to go directly to parents
or indirectly via those involved in the educating of deaf
children.
What Will Give My Child the Best
Chances of Learning to Talk?
The starting point is acquiring a language, not speech per
se. Languages can be spoken or signed, and both modali-
ties are “equal citizens” in a cognitive sense21; that is,
they fully support all human communicative needs in
daily interactions and academic endeavors. A child must
understand what language communication is about
616891CPJXXX10.1177/0009922815616891Clinical PediatricsHumphries et al
research-article2015
1University of California at San Diego, La Jolla, CA, USA
2Rochester Institute of Technology, Rochester, NY, USA
3Gallaudet University, Washington, DC, USA
4Swarthmore College, Swarthmore, PA, USA
5Universität Hamburg, Hamburg, Germany
6University of Rochester Medical Center, Rochester, NY, USA
Corresponding Author:
Donna Jo Napoli, Department of Linguistics, Swarthmore College,
500 College Avenue, Swarthmore, PA 19081, USA.
Email: dnapoli1@swarthmore.edu
Language Choices for Deaf Infants:
Advice for Parents Regarding Sign
Languages
Tom Humphries, PhD1, Poorna Kushalnagar, PhD2, Gaurav Mathur, PhD3,
Donna Jo Napoli, PhD4, Carol Padden, PhD1, Christian Rathmann, PhD5,
and Scott Smith, MD, MPH6
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2 Clinical Pediatrics
before a child can communicate with language in either
modality. As a child participates in accessible language
communication, the child begins to understand and use
language in sign and/or speech. Sign languages are
accessible to all deaf children while spoken languages
may be fully accessible only to some, via HA or CI.
Introducing 2 languages does not interfere with
acquisition of either,22-26 whether spoken or signed.27
To the contrary, many studies show signing aids
development of spoken language and reading skills in the
CI-child.28-31 In a study of CI-children who had been
learning to sign since birth, they performed in English on
par with hearing peers.32 CI-children exposed to sign and
speech tend to show rapid learning in both.33 CI-children
with deaf parents often outperform CI-children with
hearing parents on spoken language skills, presumably
because of sign competence.34 Children aged 4 to 7 years
implanted at age 12 to 24 months and educated through
oral-aural combined with signing are capable of achiev-
ing “age appropriate language levels on expressive
vocabulary and receptive syntax.”35(p1274) Signing deaf
children use their phonological awareness skills in sign-
ing to help them read a spoken language.36
How Can I Teach My Child Signing if
I Don’t Sign Myself?
Immigrant children who go to school with peers speaking
the surrounding language become fluent and speak like
their peers and the native speakers outside their home. In
particular, while their parents usually continue to use lan-
guage that is recognizably nonnative, the children do not
replicate their parents’ language use; they replicate the
language use of native speakers. So parents do not have to
be perfect language models or even very good language
models. What matters is that the child be exposed to good
language models frequently and regularly, and models
outside the home can serve that function very well.
However, even if not fluent, the parents’ language use
is still important to the language development of the
child. Children need to interact directly through language
with their family members in order to develop healthy
relationships with those members; the alternative leads to
feelings of isolation and frustration. When a hearing
mother signs with her deaf child, the child shows early
language expressiveness on a par with hearing peers37
regardless of her signing abilities. And deaf children who
have good family relationships have a better chance of
developing healthy psychosocial identities.38
In sum, when deaf children are placed into environ-
ments with good sign language models, they learn to
sign fluently, even if their family does not.39 Most cities
have deaf and hearing communication centers that offer
sign language classes for families and that can help fam-
ilies make ties with deaf community members. (A list of
useful websites is offered at the end of this article.)
Won’t There Be Less Family
Disruption and Less Work if I Raise
My Child Strictly Orally?
The presence of a deaf child changes family dynamics
regardless of language(s) used.
If your child has HA or CI, it might be possible for
him or her to become linguistically competent and happy
using speech only. The training necessary for having a
chance at speech competence requires daily commit-
ment of time and effort on the part of all those involved
in raising and educating the child. But, importantly, it
also requires enormous persistence on the part of the
deaf child. If oral language skills enable the child to
communicate with hearing strangers, these skills might
open up additional social and professional opportunities,
to be sure. However, there is no assurance that any of
this will happen, no matter how much time and effort are
devoted to training. And if it doesn’t happen, not only
will the child have wasted great amounts of time that
could have been spent in play (important to learning)
and more fruitful activities, but the child may well expe-
rience a sense of failure.
On the other hand, sign language skills ensure the
child’s cognitive health and avoid family frustration.40
Furthermore, the deaf child will have a language in
which to be comfortable, where the child can acquire
knowledge, catch jokes, and appreciate nuances of lan-
guage necessary to socialize, relax, and be eloquent.
Learning a sign language will definitely require time
and effort of the family, but for the deaf child it is a natu-
ral process that does not require extra effort.
Won’t Signing Adversely Affect My
Child’s Academic Achievements?
After All, Bilingualism Is Confusing
Knowing a sign language does not impede a deaf child’s
academic achievements. In fact, good signing skills pro-
mote the acquisition of literacy, both reading and writ-
ing, as study after study has shown.41-49 It’s actually
simple: A child needs a solid foundation in a first lan-
guage in order to understand what literacy is all about,
and a sign language is the best way to give a deaf child
that foundation.50
So deaf children need to be raised bilingually—in
both their local sign language and the ambient spoken
language, at least the written form of it. Bilingualism
might be considered a luxury for hearing children in
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Humphries et al 3
some places, but bilingualism is necessary for a deaf
child, to ensure intact language capabilities and social-
cultural development.
Parents can rest assured that bilingualism will not
harm their children, but, instead, bestow “the bilingual
advantage.”51 The bilingual brain is quick, focused, and
flexible. Bilinguals are “mental jugglers” with enhanced
executive function.52 Frequent juggling between lan-
guages increases cognitive benefit—and this goes for
bimodal bilinguals too53—whether one is a “balanced
bilingual” or not, although the more nearly balanced one
is, the more benefit for spontaneous cognitive flexibil-
ity.54 Bilinguals show enhanced sensitivity to language
distinctions,55 which is an advantage in language pro-
cessing.56 Bilingualism retards the onset of dementia.57
Being raised bilingual improves language functioning
and higher level cognitive skills in children with lan-
guage impairments.58
Can’t We Wait to See if Our Child
Succeeds with a CI Before Working
to Learn to Sign?
The earlier children are exposed to a language, the
greater guarantee of fluency. Infants with an intact audi-
tory system differentiate sounds of the surrounding lan-
guage from sounds of unfamiliar languages,59 and a
child’s ability to distinguish between articulations (audi-
tory or manual) of her surrounding language in the first
year of life predicts language abilities in the second and
third years of life.60 Early intervention services deliv-
ered before 6 months of age result in better receptive and
expressive language.61 If the CI does not provide the
deaf child this critical early language access, as it often
does not, waiting to introduce signing runs the risk that
she might miss the window for language fluency.
But Won’t I Lose My Child to Deaf
Culture?
Parents who sign are not more likely to “lose” their chil-
dren. In fact, logically, parents who sign strengthen the
bond with their deaf child. Children who associate with
other deaf people are not lost to their hearing families.
Deaf children’s experience will always be different from
their hearing parents, but they will also share much with
them if the family signs. Acceptance and love build
strong family bonds, not whether someone speaks or
signs. Having a strong sense of self supported by others
with the same experience gives deaf children, just like
hearing children, a sense of purpose and happiness,
important for future success.62
Useful Websites
For families:
http://handsandvoices.org/
http://www.babyhearing.org/index.asp
http://idea.ed.gov/
http://www.wfdeaf.org/
http://raisingandeducatingdeafchildren.org/
the-earliest-interventions-when-parents-discover-
they-have-a-deaf-child
http://www.deaflinx.com/resources/resources-for-
parents-with-deaf-and-hard-of-hearing-children.html
For both families and professionals:
http://www.nidcd.nih.gov/
http://www.asha.org/
http://www.gallaudet.edu/documents/clerc/ei.pdf
(This is an article: Early Beginnings for Deaf and
Hard of Hearing Children: Guidelines for Effective
Services)
http://www.infanthearing.org/
For introduction to sign:
http://www.lifeprint.com/
http://www.aslpro.com/
http://www.handspeak.com/
http://www.funbrain.com/signs/index.html
http://www.asl.ms/
https://www.signingsavvy.com/
Author Contributions
All authors substantially contributed to the concept and design
of this article, helped in drafting and revising it, and approved
this final version for publication.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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