The acquisition of sign language by deaf children with autism spectrum disorder

Full text

90
The Acquisition of Sign
Language by Deaf Children
with Autism Spectrum
Disorder
Aaron Shield and Richard P. Meier
Introduction
Autism spectrum disorder (ASD) consists of a set of neurobiological
developmental disorders characterized by communicative and social deficits
as well as repetitive, stereotyped behaviors.1 In this chapter, we use the
terms ‘ASD’ and ‘autism’ interchangeably; although ‘autism’ is not a clinical
term, it is the term popularly used to refer to the range of disorders found
in ASD.
The language deficits of hearing children with autism are well docu-
mented, and can range from the very mild in highly fluent speakers to the
very severe in children with a total absence of productive spoken language.
For those children who do acquire speech, the most common characteristics
of autistic language include echolalia (echoing the utterances of others),
pronoun reversal, idiosyncratic language use and neologisms (the creation
of new words), difficulty with pragmatics (problems interpreting the use
of language in context and the non-literal use of language), and abnormal
intonation and vocal quality. Although relatively little research to date has
focused on the sign language deficits of deaf children with autism, in this
chapter we will review what is currently known about the sign language
of such children. It is worth noting from the outset that virtually all
work on this population has occurred since 2010, and findings are still
preliminary.
Apparent dramatic increases in the rates of autism in the general popula-
tion (1 in 88 children in the United States; Centers for Disease Control, 2012)
4
2639_Ch04.indd 902639_Ch04.indd 90 05-12-2013 18:40:2605-12-2013 18:40:26

have been widely publicized. Since autism is a brain disorder and occurs
whether or not hearing is intact, it is likely that autism affects at least as high
a percentage of the deaf population as the general population. Indeed,
Szymanski et al. (2012) recently reported that 1 in 59 deaf or hard of hearing
children in the 2009–2010 Annual Survey of Deaf and Hard of Hearing
Children and Youth (Gallaudet Research Institute, 2011) carried an ASD
diagnosis. Chess et al. (1978) reported that 7% of 243 students deafened by
rubella had autistic symptoms, while Jure et al. (1991) found that 46 (4%) of
a sample of 1150 children with hearing impairment also carried a diagnosis
of autism. Conversely, there is evidence that severe hearing loss occurs at a
higher rate in the autistic population (3.5%; Rosenhall et al., 1999) than in
the general population (0.3%; White, 2004).
In this chapter, we seek to introduce the community of sign language
researchers to the theoretical and practical issues involved in autism research.
Our aim is to describe what is known about the interaction of autism with
sign acquisition, discuss how the social, cognitive and linguistic deficits of
autism are likely to impact sign language acquisition, and suggest areas that
may be particularly fruitful for future research.
Methodological problems
Sign language researchers interested in autism wil l immediately encoun-
ter a methodological hurdle in their research: no diagnostic instruments
have yet been designed specifically for deaf children, although several
instruments are – at the time of this writing – in the process of being
adapted for use with deaf children. Still, current gold standard instruments
such as the Autism Diagnostic Observation Schedule, Second Edition
(ADOS-2; Lord et al., 2012) or the Autism Diagnostic Interview – Revised
(ADI-R; Lord et al., 1994) have yet to be adapted for deaf children, and the
ADOS explicitly warns against use with deaf children. Moreover, recent
research has demonstrated that behavioral checklists widely used as ASD
screening instruments lack sensitivity when used with deaf chil-
dren: Szymanski (2010) found that only 50% of 52 deaf children with a
reported diagnosis of an ASD scored in the clinically significant range on
three common screeners for ASD, the Gilliam Autism Rating Scale – Second
Edition (GARS-2; Gilliam, 2006), the Social Communication Questionnaire
(SCQ; Rutter et al., 2003), or the Social Responsiveness Scale (SRS;
Constantino, 2002). It is thus possible that ASD could be under- identified in
deaf children, given the lack of appropriate diagnostic and screening instru-
ments. Accurately diagnosing a deaf child with ASD remains a formidable
obstacle, and often requires the judgment of clinicians who are both expert
in ASD and familiar with deaf children.
The translation and adaptation of such instruments for use with deaf
children is likely to be complex, as some of the items are inappropriate for
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 91
2639_Ch04.indd 912639_Ch04.indd 91 05-12-2013 18:40:2605-12-2013 18:40:26

deaf children. For example, one item on the ADOS concerns the child’s
response to his/her name being called by the examiner. The purpose of this
task is ‘to observe the consistency of the child’s response to a hierarchy of
auditory stimuli’ (ADOS module 1, p. 2) and to see what the examiner needs
to do in order to get the child’s attention. It is unclear how this item would
be adapted for use with a deaf child. There is no sign language equivalent of
calling a child’s name, although there are conventional attention-getting
behaviors in the Deaf community (hand-waving, foot-stomping, or touching
a person on the shoulder). How would these various behaviors be scored, and
are they all equivalent to calling the child’s name? Other parts of the ADOS
are problematic as well, including items scoring pointing, gesture, facial
expressions and intonation of vocalizations, all of which would require sig-
nificant adaptation for deaf children acquiring sign. Until appropriate test
instruments are published, it will remain difficult to be certain that an
autism diagnosis for a deaf child is correct. Several studies have documented
that diagnosis of ASD in deaf children is often delayed, if it occurs at all:
Roper et al. (2003) found that the mean age of diagnosis in their sample of
nine deaf ASD British children was 15;0 (range 5;0–16;0), compared with 7;5
(4;0–11;0) in a group of hearing autistic children. Jure et al. (1991) similarly
reported that autism diagnosis was delayed in their sample of 46 hearing-
impaired autistic children, with some children not being diagnosed until age
17. Mandell et al. (2005) found that diagnosis of ASD in deaf children lagged
behind hearing children by approximately one year.
Although we believe that it is advantageous to expose deaf children to a
visual language that is more fully accessible to them than is speech, the
acquisition of sign is nonetheless likely to be challenging for deaf children
with ASD. This is because some of the social skills impaired in autism are
particularly crucial for the acquisition of signed language, and could lead to
sign-specific linguistic deficits.
Indeed, the visual-gestural modality of sign relies crucially on a set of
social, perceptual and articulatory skills that are known to be impaired in
autism. We will mention three obstacles that may confront children with
autism. First, hearing children with autism differ both from typically devel-
oping (TD) children and from children with other kinds of developmental
delay in their limited use of gesture; children with autism produce signifi-
cantly fewer gestures (Buitelaar et al., 1991) and are developmentally less
advanced in their use of gesture (Mundy et al., 1986). Although non-linguistic
gesture should not be confused with sign, sign and gesture are both articu-
lated with the hands, and signers gesture while they sign. Could a deficit in
gesture impact how deaf children with ASD acquire sign? Secondly, the per-
ception and comprehension of visual linguistic stimuli by autistic children
could be disrupted by a variety of known deficits in the areas of eye gaze,
face-scanning behavior and comprehension of facial expression. Thirdly,
hearing children with autism often show impairments in the ability to
92 Part 1: Developmental Language Disorders in the Signed Modality
2639_Ch04.indd 922639_Ch04.indd 92 05-12-2013 18:40:2605-12-2013 18:40:26

imitate the body movements of others (Williams et al., 2004) and exhibit a
variety of motor deficits (Ming et al., 2007) that could lead to articulatory
problems in sign. Thus, the acquisition of sign by autistic children is likely
to be affected by these social, perceptual and motoric deficits.
In the next sections, we will describe what is known about the interac-
tion of autism with sign acquisition in both hearing and deaf children.
What is Known About the Interaction of Autism
with Sign Acquisition?
Few studies have examined the signing of deaf children or adults on the
autism spectrum, although there have been several case studies of deaf chil-
dren with autism who do not sign. For example, Brimer and Murphy (1988)
reported the case of a deaf autistic boy, but focused exclusively on his acquisi-
tion of English, and Malandraki and Okalidou (2007) described a 10-year-old
deaf Greek child with autism who was trained to use the Picture Exchange
Communication System (PECS; Bondy & Frost, 1994), but was not taught a
sign language.
Poizner et al. (1990) reported a single 21-year-old deaf autistic signer who
exhibited sign echolalia. Morgan and colleagues have reported extensively on
the British Sign Language (BSL) acquisition of Christopher, a hearing lan-
guage savant with autistic characteristics (Morgan et al., 2002a, 2002b, 2007;
Smith et al., 2011).2 These reports contain some of the most detailed sign
language data available about a person with autism. We will discuss the find-
ings on Christopher in a later section.
More recently, two studies in particular have investigated specific sign
language structures in the signing of deaf children with autism. Denmark
(Denmark, 2011; Denmark et al., 2009) studied how deaf British children and
adolescents on the autism spectrum produce and perceive facial grammar in
BSL, while Shield (2010) and Shield and Meier (2012) analyzed formational
errors in the signing of deaf American children with autism. These studies
will also be described in detail in later sections.
In contrast to the few studies on the signing of deaf children with autism,
there is a rich literature on the therapeutic use of signs as an alternative to
speech for hearing children with severe autism. Despite the limitations of
these studies, it is worth reviewing the major findings of these works, which
are reported below.
Sign language and hearing children with autism
In the late 1960s, an interest developed in the ability of autistic children
to learn signs – particularly children who had failed to acquire speech
following intensive speech therapy. It was suggested that some non-verbal
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 93
2639_Ch04.indd 932639_Ch04.indd 93 05-12-2013 18:40:2605-12-2013 18:40:26

autistic children ‘complied readily if gesture or demonstration were used to
convey the request’ (Webster et al., 1973: 338). Another paper reported, ‘We
have found it impossible to teach some children to speak. Yet some of these
same children have learned to express themselves quite rapidly once they
have been shown how to use their hands’ (Stull et al., 1979: 144). As a result
of these early studies, sign was seen as a possible alternative communication
mode for autistic children who had failed to acquire speech. Numerous stud-
ies in the late 1970s and early 1980s performed interventions with non-
verbal autistic hearing children (for reviews, see Bonvillian et al., 1981; Carr,
1979). These children were taught manual signs either alone or in addition
to speech.
Although these papers are not sufficiently detailed to enable a proper
analysis of the signs that the children produced, the results showed that
some autistic children were successful at learning signs, even when previous
attempts to teach spoken words had failed. Bonvillian et al. (1981: 128), in
their review of over 20 studies involving the teaching of signs to more than
100 children with autism, note that:
results of these studies indicate that even fairly brief simultaneous com-
munication or sign language training can be an effective means of
improving communication skills in low-functioning autistic children.
Despite an extensive range of individual outcomes, almost every subject
acquired the ability to comprehend trained signs.
Bonvillian et al. reported that the children acquired vocabularies ranging
from five signs to over 350 signs, although Bonvillian and Blackburn (1991:
276) suggested in a later paper that ‘statements in the literature about the
sign vocabulary sizes of autistic children . . . may considerably over-represent
their real working vocabularies’ because most of the signs trained to criterion
in such studies were not observed in spontaneous usage outside of training
sessions. Still, researchers argued that signs could be advantageous over
speech because children’s hands can be guided and molded, and signs can be
exaggerated, enlarged or frozen to allow for additional processing time
(Jordan, 1990). As various researchers have noted (recently, Pizer et al., 2011),
deaf mothers of TD deaf children also sometimes enlarge their signs or mold
their children’s hands in the acquisition process.
Importantly, most of the signs acquired by these hearing children with
autism were nouns, while there are contradictory claims in the literature
about the ability of these children to master what Carr (1979: 353) called
‘abstract sign language . .. prepositions, pronouns, and other abstractions’. A
few researchers reported success: Creedon (1973) claimed that her 21 for-
merly non-verbal autistic subjects between the ages of four and nine achieved
great success in many areas of language acquisition after an intervention
employing simultaneous communication (that is, the simultaneous use of
94 Part 1: Developmental Language Disorders in the Signed Modality
2639_Ch04.indd 942639_Ch04.indd 94 05-12-2013 18:40:2605-12-2013 18:40:26

spoken and signed English). Similarly, Bonvillian et al. (1981: 128) reported
that ‘in many cases children moved to daily production of many complex
sign utterances’, although it is not clear what kinds of ‘complex sign utter-
ances’ were produced by these children. Indeed, any claim about the acquisi-
tion of complex structures must be looked at skeptically. As Bonvillian et al.
(1981: 130) note:
[the] absence of detailed records of most of the children’s sign language
combinations makes it impossible to determine for fairly fluent children
whether there is sufficient regularity of syntax or comprehension of com-
plex semantic aspects in the children’s sign utterances to credit them
with these fundamentals of language.
Thus, despite the large number of studies on the subject, the available data
are insufficient to determine if sign intervention with hearing ASD children
(whether using American Sign Language [ASL] or Signed English) facilitates
the mastery of complex grammatical structures. For most children, the data
indicate that sign learning is limited to a small number of simple signs, after
which they ‘make only limited progress in terms of the average length and
complexity of their sign utterances’ (Bonvillian et al., 1981: 130).
In general, these studies provide little information about the form or use
of signs produced by children with autism. Only one study (Seal &
Bonvillian, 1997) looked at the form of signs produced by a sample of chil-
dren with autism, all of them hearing. They analyzed the sign production
of 14 low-functioning hearing autistic students (12 male, 2 female) who
were enrolled at a residential school for children with developmental disor-
ders and who ranged in age from 9;2 to 20;4 (mean age 13;8). The goal of the
study was ‘to determine the sign formational elements that autistic children
successfully and unsuccessfully produced in making their signs’ (Seal &
Bonvillian, 1997: 440), with an eye towards ‘uncovering associations
between autistic children’s signing and any underlying motor deficits’ (Seal
& Bonvillian, 1997: 439). Focusing on the sign parameters of handshape,
location, and movement3 (see Editor’s Introduction, this volume), they ana-
lyzed 348 signs produced by the children with autism. Although there was
wide variability in error rates across the participants, locations were pro-
duced more successfully (16% error rate) than either handshapes or move-
ments (36% error rate for both). Three locations – neutral space, the chin
and the torso (trunk) – accounted for nearly three-quarters of subjects’
signs. The movement parameter was difficult for subjects and the source of
many formational errors. Signs that exhibited a contacting action with the
body were produced most accurately, while several frequently occurring
movements (twisting, toward-the-body, circling and away-from-the-body)
had high error rates, ranging from 43% to 53%. Also, subjects tended to add
epenthetic movements – extra movements not included in the citation form
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 95
2639_Ch04.indd 952639_Ch04.indd 95 05-12-2013 18:40:2705-12-2013 18:40:27

– and to reduce signs consisting of two or three sequential movements to a
single movement.
The size of the students’ vocabularies and their accuracy in articulating
signs were highly correlated with scores on tests for fine motor age and
apraxia, a neuromotor disorder that impairs the ability to perform pre-
planned or voluntary motor movements. Seal and Bonvillian (1997) inter-
preted this result as an indication that sign formation errors could result in
part from underlying motor deficits. However, they explicitly rejected the
idea that such deficits could be the sole explanation for the communicative
difficulties of autistic children, allowing for the possibility that there could
be cognitive and perceptual reasons for such errors as well.
A later study (Soorya, 2003) further explored the relationship between
motor skills, apraxia (a motor planning disorder that results in an inability
to carry out planned movements), and the acquisition of signs by hearing
children with autism. In two experiments, Soorya compared 12 children
with autism to TD children who were matched for either mental or chrono-
logical age. She found that the children with autism performed significantly
more poorly than mental-age-matched TD children on apraxia tests, but not
on motor tests. However, she did not find differences between children with
autism and mental-age-matched T D children on sign language production or
comprehension.
Collectively, these studies on hearing children accounted for the prepon-
derance of work on sign and autism until very recently. The paucity of stud-
ies of deaf children – particularly studies of deaf children of deaf parents
exposed to a sign language from birth – limits our ability to understand how
autism affects sign language development. Two earlier studies (Bonvillian &
Blackburn, 1991; Ornitz & Ritvo, 1976) reported the presence of deaf or
hearing-impaired subjects within their study populations, but data from
those subjects were analyzed together with the hearing subjects. Poizner
et al. (1990) and Denmark (2011) both observed a single native deaf signer in
their studies. To our knowledge, only our own study (Shield & Meier, 2012)
has reported on multiple native-signing children on the autism spectrum. In
studies of theoretical significance, in which the goal is to understand how
autism affects cognition, it is preferable to include children exposed to sign
language since birth (deaf-of-deaf children), inasmuch as deaf children of
hearing parents have documented developmental and language delays (Schick
et al., 2007) that could obscure the effects of autism on language and cogni-
tive development. Since 90–95% of deaf children are born to hearing parents
(Mitchell & Karchmer, 2004), identifying and recruiting native-signing autis-
tic children represents a formidable methodological challenge.
Therefore, most previous studies on the acquisition of sign by children
on the autism spectrum, although useful in describing a possible alternative
communication strategy for hearing children when speech training has
failed, do not help us understand how the core deficits of autism interact
96 Part 1: Developmental Language Disorders in the Signed Modality
2639_Ch04.indd 962639_Ch04.indd 96 05-12-2013 18:40:2705-12-2013 18:40:27

with language acquisition in the visual-spatial modality. A question of fun-
damental importance is whether the linguistic characteristics of autistic
signing are the same as those of autistic speech. Identifying the characteris-
tics of autistic signing may clarify the role of modality in language acquisi-
tion, insofar as sign and speech draw upon somewhat different sets of
perceptual, cognitive and social skills. Differences in the linguistic profiles of
deaf and hearing autistic children would provide strong evidence for the
effects of these modality differences. In the next two sections, we will exam-
ine two of the most well documented characteristics of autistic speech –
echolalia and pronoun reversals – as a way to analyze the interaction of
modality with the deficits of autism.
Echolalia
Echolalia4 is the repetition of other people’s vocal productions, which can
occur either immediately or with a delay. It was first reported in autistic chil-
dren by Kanner (1943) and is ‘the most frequently cited characteristic of verbal
autistic children’ (Prizant & Duchan, 1981), affecting up to 85% of the autistic
children in some studies (Schuler & Prizant, 1985). All children repeat other
people’s utterances, and indeed imitation is a necessary building block for lan-
guage acquisition. It is the extreme and exact nature of autistic children’s rep-
etitions that make them noteworthy; they may reflect a ‘gestalt’ approach to
language acquisition (Prizant, 1983) rather than the analytic mode typical of
normal language acquisition (Bloom & Lahey, 1978; Peters, 1983).
Is echolalia a modality-independent function of the autistic child’s
approach to language, or a specific effect of the vocal-auditory modality?
Several reports of echolalia in signing children with autism suggest that it is
the former. Poizner et al. (1990) described the signing of a 21-year-old native-
signing deaf woman with autism whom they call Judith M. Despite the rich
signing environment in which she was raised – her deaf parents and two
elder brothers communicated exclusively in sign – Judith M. produced her
first sign at age five. Poizner et al. (1990: 68) report a simple exchange
between Judith M. and her father, in which the majority of her utterances
are echolalic:
Father: Do you want to see a train?5
Judith M.: SEE TRAIN. [An imitation of sign just produced by her father.]
Father: First, we will...?
Judith M.: FIRST. [Imitation.]
Father: Second, we will. ..?
Judith M.: SECOND... STORE.
Father: Yes, we will go to the store. Third, we will. ..?
Judith M.: THIRD. [Imitation.]
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 97
2639_Ch04.indd 972639_Ch04.indd 97 05-12-2013 18:40:2705-12-2013 18:40:27

Father: Yes, we will be home soon.
Judith M.: HOME, SOON. [Imitation.]
Father: What will we do on Wednesday?
Judith M.: STORE... TRAIN.
Father: That again?
Judith M.: AGA IN. [Imitation.]
Father: Father and Judith M. will go to a store.
Judith M.: STORE... FIRST... SECOND.
Father: In the morning, we first go to the store.
Judith M.: FIRST. [Imitation.]
The authors indicate that Judith M. exhibited no evidence of grammatical
knowledge, morphology or syntax. Her signing consisted largely of imita-
tions of signs produced immediately before by her interlocutor. She rarely
initiated communication or signed spontaneously. It is worth noting that
this case study demonstrates that children raised in signing households can
also have severe language problems, just as some hearing children with
autism do: sign is not a panacea for children with language disorders.
There are several other mentions of sign echolalia in the literature. Smith
et al. (2011) have reported that Christopher, upon first exposure to BSL,
would often repeat signs without understanding them.6 Of 27 deaf children
with autism exposed to sign language in Jure et al.’s (1991) study, 21 could
sign words or phrases, and five of these produced echolalic utterances.
Finally, follow-up analyses of the data reported in Shield (2010) revealed that
one participant, a deaf girl of deaf parents age 11;9, showed markedly echo-
lalic signing, repeating the instructions to tasks as the experimenter signed
them. For example, in introducing a task in which a novel object was labeled
with a nonsense sign, the experimenter signed I INVENT SIGN, YOU-
COPY-ME, YOUR-TURN. The child echoed each sign produced by the
experimenter, signing back I INVENT SIGN, YOU-COPY-ME, YOUR-
TURN. The fact that she did not maintain pronominal or verb agreement
reference strongly implies echolalic signing without comprehension. We thus
feel confident, even at this early stage, in concluding that echolalia is a
modality-independent phenomenon characteristic of both autistic speech
and autistic signing.
In the next section, we turn to another hallmark of autistic speech, pro-
noun reversal. Although pronoun reversal may be related to echolalia in some
instances, there is reason to suspect that the cognitive deficit underlying
pronoun reversal in autistic speech may lead to quite different effects in sign.
Pronoun reversal
Pronoun reversal – especially the reversal of the first- and second-person
pronouns I/me and you – is more common in children with autism than in
98 Part 1: Developmental Language Disorders in the Signed Modality
2639_Ch04.indd 982639_Ch04.indd 98 05-12-2013 18:40:2705-12-2013 18:40:27

any other group (Lee et al., 1994). It was originally noted by Kanner (1943),
who believed that the pronoun reversals found in his case studies were
related to echolalia:
[Don] always seemed to be parroting what he had heard said to him at
one time or another. He used the personal pronouns for the persons he
was quoting, even imitating the intonation. When he wanted his mother
to pull his shoe off, he said: ‘Pull off your shoe.’ When he wanted a bath,
he said: ‘Do you want a bath?’
Since Kanner’s seminal paper, pronoun reversals in the speech of hearing chil-
dren with autism have been reported in many other studies (e.g. Bartak &
Rutter, 1974; Charney, 1980). TD children also sometimes reverse pro-
nouns early in development, between the ages of 1;7 and 2;4 (Chiat, 1982;
Clark, 1978; Oshima-Takane, 1992; Schiff-Myers, 1983), but this is a tran-
sitory phase, and does not persist (Bartak & Rutter, 1974; Dale & Crain-
Thoreson, 1993).
Several hypotheses have been advanced to explain the difficulty that
many autistic children have in mastering first- and second-person pronouns.
One theory has emphasized pragmatic factors, particularly ‘in conceptual-
izing the notion of self and other as it is embedded in shifting discourse roles
between speaker and listener’ (Lee et al., 1994; Tager-Flusberg, 1993, 1994,
2000). Thus, a child acquiring language must come to understand that the
meaning of pronouns depends on who the speaker is: I is not a name for any
particular person, but rather refers to the speaker of a given utterance.
According to this hypothesis, not just pronouns but all deictic terms should
cause problems for people with autism. Indeed, Hobson et al. (2010) found
that a majority of children with autism in their sample (but not a single one
of the children without autism) incorrectly referred to a location that was
distal to themselves with the more proximal terms this or here, and scored
significantly lower on a task in which they were asked to place toy animals
either close to or distant from themselves after receiving instructions con-
taining contrasting terms such as this and that, here and there, bring and take,
and come and go.
A second hypothesis that is particularly interesting for the study of sign
language is that the proper use of person pronouns could require a more
general understanding of people’s differing spatial perspectives. In one study,
Loveland (1984) tested a group of 27 TD children between the ages of 2;0 and
3;3 on the comprehension and production of first- and second-person subject
and possessive pronouns as well as the understanding of differing visual per-
spectives. She found that only children who demonstrated comprehension of
other people’s different spatial points of view made no errors on pronouns,
suggesting that an appreciation of the spatial perspectives of others is a cog-
nitive prerequisite for the proper acquisition of pronominal forms. In another
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 99
2639_Ch04.indd 992639_Ch04.indd 99 05-12-2013 18:40:2705-12-2013 18:40:27

study, Ricard et al. (1999) tested French- and English-speaking toddlers on
visual perspective-taking skills and pronoun usage. They found that perfor-
mance on perspective-taking tasks was correlated with pronoun acquisition,
and that the ability to coordinate two perspectives preceded mastery of first-
and second-person pronouns. Thus, there is some evidence that visual per-
spective-taking skills underlie the pragmatic understanding necessary for the
proper use of pronouns in speech. Although results have been mixed, several
studies (Hamilton et al., 2009; Reed, 2002; Warreyn et al., 2005) have shown
that children with ASD are impaired in their ability to understand the dif-
fering visual perspectives of others.
Unlike pronouns in spoken languages, which are arbitrary combinations
of sounds unrelated to their meaning, pronouns in signed languages tend to
be indexical points to the intended referent. Despite this transparency, there
is evidence that some TD deaf children produce pronoun reversals at a stage
early in development. Petitto (1987) found reversals in first- and second-
person pronominal points produced by two TD native-signing deaf children
between the ages of 21 and 23 months. However, she argued that these rever-
sals were not due to a perspective-taking failure, but rather to an over-lexi-
calization of indexical points, effectively turning a deictic point into a frozen
lexical item. In other words, the signing child interpreted the points directed
at her (the ASL pronoun YOU) as her name, and would thus produce a point
outwards from herself in reference to herself. This is indeed how lexical
items (but not pronouns) in signed languages typically work, as Petitto (1987:
42) observed in the same paper:
Learning signs requires that the child be able to perform a spatial trans-
formation, such that what she produces is the mirror image of what she
sees, rather than its literal form. Failure to perform this transformation
would result in perceptually-based errors. . . . Essentially, the child should
sign backwards.
We will return to this important observation about the nature of sign later,
in our discussion of reversal errors in autistic signing.
To date, Petitto’s study is the only report of pronoun reversals in sign,
although Casey (2003) has reported a similar instance of a reversed verb
(GIVE-YOU to mean ‘give me’, produced by a two-year-old TD deaf child).7
Hatzopoulou (2010) studied the acquisition of pronouns in Greek Sign
Language by one native-signing deaf Greek child between 12 and 36 months
of age, but did not find pronoun errors. While it is clear that pronoun rever-
sals in sign are possible, it is not yet clear how pervasive this phenomenon is,
and whether reversals occur in sign for the same reasons they occur in speech.
There are no documented reports of pronoun reversals in the signing of
deaf children with autism, t hough some authors have presumed ( prematurely,
it would seem) that pronoun reversals will occur in autistic signing, just as
100 Part 1: Development al Language Disorders in the Signed Modalit y
2639_Ch04.indd 1002639_Ch04.indd 100 05-12-2013 18:40:2705-12-2013 18:40:27

in autistic speech (e.g. Collins & Carney, 2007). Some of this confusion may
have stemmed from studies which have documented pronoun reversals in
the speech of deaf children (Oshima-Takane et al., 1993).
Shield (2012) analyzed the spontaneous production of pointing signs,
including pronouns, by four native ASL users with autism between the ages
of 4;6 and 7;5. In 20-minute samples taken from naturalistic data in his dis-
sertation, he found that all four children produced points, and that these
points included points to self (i.e. first-person pronouns), points to others
(second/third person pronouns) and points to objects. Two children pro-
duced five points each, one child produced 11 points, and one child produced
25 points. He analyzed the points to self and others in discourse for intended
reference but did not find evidence of reversals.
Despite the lack of documented pronoun reversals in the signing of deaf
children with ASD, there may still be abnormalities in pointing behavior. In
interviews reported by Shield (2010), four Deaf mothers of deaf children
with autism reported abnormalities in how their children referred to them-
selves and to others. One mother indicated that her son would sometimes
refer to himself with his name sign rather than an indexical point (pronoun),
although note that she also reports correct pronominal usage:
[My son] can point to himself as in I WANT FOOD. Before he used to
sign [his sign name]. I corrected him, instructing him to not say his name
and instead to point to himself. He learned that about three or four years
ago [when he was between the ages of four and five]. Now he points to
himself. Sometimes he alternates between pointing to himself and sign-
ing his name sign8 .. . When he refers to us, he points a little bit, but he
tends to fingerspell our names. He will sign MOMMY, fingerspell his
brother’s name, and sign his own name sign. He seldom points to refer
to us. Occasionally, if he fights with his brother, he will point to [his
brother] emphatically and yell YOU WRONG (‘you’re wrong!’). He points
at his brother and doesn’t sign his name. But if he comes up to me, he
will use his brother’s name sign instead of a point.9
Another mother stated that her son did not use points to refer to people, but
did use points to make requests:
I don’t see pointing from [my son] at all. But long ago, when he was
younger, he used to point to things to express what he wanted. For exam-
ple, if he wanted something like food, he would point at the refrigerator
incessantly. He used to point at things to make requests, but he stopped.
Since then, I don’t see him pointing.
These maternal reports are consistent with studies reporting abnormal point-
ing behavior in the communicative gestures of hearing children with autism
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 101
2639_Ch04.indd 1012639_Ch04.indd 101 05-12-2013 18:40:2705-12-2013 18:40:27

(Ricks & Wing, 1975). Baron-Cohen (1989) found that protodeclarative point-
ing (as in sharing or commenting on an object) is impaired in autism, though
protoimperative pointing (as in requesting) is not. Other studies have con-
firmed that gestures used for requesting objects, actions or social routines
may be present in autism (Attwood et al., 1988; Loveland & Landry, 1986),
while gestures sharing an awareness of an object’s existence or properties are
absent (Curcio, 1978; Mundy et al., 1986, 1987; Wetherby, 1986).
We cannot yet say with confidence whether pronoun reversals are char-
acteristic of the signing of deaf children with autism, or indeed if they occur
at all. However, converging findings in the areas of gesture imitation and
sign language acquisition suggest that the same cognitive deficits that under-
lie pronoun reversal in hearing children with autism will affect various levels
of structure in sign, from the sub-lexical to the morphological. In the next
section, we will provide evidence for this hypothesis from studies on gesture
imitation in autism, and then proceed to more recent work on acquisition of
sign by deaf children with autism.
Imitation of gestures in autism
Children with autism are impaired in their ability to imitate others,
although the exact nature of this impairment, as well its underlying cause,
has occasioned much debate. Most studies on the subject have found an
imitation deficit in autistic subjects (although a few studies have not; e.g. see
Morgan et al., 1989). DeMyer et al. (1972) found that children with autism
were impaired in their ability to imitate the bodily actions of others as well
as motor-object actions, such as stringing beads. Curcio (1978) found that
non-verbal children with autism between the ages of four and 12 performed
poorly on gestural imitation, a finding that has been replicated in other stud-
ies (e.g. Dawson & Adams, 1984).
These deficits have led to different accounts of what underlies the imita-
tion impairment in autism. Smith and Bryson (1994: 262), in their review of
15 studies of the imitation skills of autistic children, commented that these
studies ‘provide some support for the existence of a specific imitative deficit
in autism but are uninformative as to its nature.’ In another review of 21
studies of imitation by autistic subjects, Williams et al. (2004) concluded that
of the six major theories advanced in the literature about the nature of the
imitation deficit in autism, a specific deficit in self-other mapping abil-
ity (Rogers & Pennington, 1991) was most consistent with the evidence pre-
sented. Self-other mapping refers to the process(es) by which children or
adults are able to observe the movements of others and map those observed
movements onto their own bodies, thus reproducing the movements
accurately.10
The most compelling evidence for this theory is the striking finding of a
number of studies (Brown, 1996; Hobson & Lee, 1999; Ohta, 1987; Smith &
102 Part 1: Developmental Language Disorders in the Signed Modalit y
2639_Ch04.indd 1022639_Ch04.indd 102 05-12-2013 18:40:2705-12-2013 18:40:27

Bryson, 1998; Whiten & Brown, 1998) that when autistic children attempt
to imitate the arm and hand movements produced by others, they sometimes
reverse palm orientation and the direction of these arm movements. Ohta
(1987) was the first to report such errors (which he called ‘partial imita-
tions’) in imitations of gestures. Children with autism showed a tendency to
imitate a wave-like gesture in which the experimenter’s open palm was ori-
ented toward the child with a gesture in which the palm was oriented
inward toward the child him/herself. Later, Smith and Bryson (1998) found
that children with autism made significantly more 180° reversal errors in
palm orientation than age-matched language-impaired and TD children in
the imitation of eight ASL handshapes and eight bimanual gestures.
These errors appear to be unique to autism. They have been observed in
a variety of contexts, including the imitation of object-related actions, pan-
tomimes, and meaningful and meaningless gestures. Like the spoken lan-
guage pronominal reversals discussed earlier, these errors may reflect a
general ability to imitate words and gestures but a specific difficulty with the
shifts in perspective needed to use spoken language pronouns correctly or to
imitate manual gestures accurately. Instead, children with autism tend to
replicate bodily movements as observed from their own point of view, not as
they are produced by the person they are attempting to imitate. This finding
has clear implications for the acquisition of sign by deaf children with
autism, since palm orientation and direction of arm movements have linguis-
tic value in sign. For example, the ASL signs PAPER and CLEAN vary only
in the direction of movement of the dominant hand. If the sign-learning
child reproduces a sign’s direction of movement as observed from his own
perspective, such an error could lead to an unintended meaning. This out-
come could also arise with pairs of signs that differ primarily or solely in
their palm orientation, such as the ASL signs TUESDAY (palm inward) and
TOILET (palm outward); see Figure 4.1.
There is evidence that indeed, the same reversal errors found in the imita-
tion of gesture by hearing children with autism also appear in the production
of signs by deaf children with autism. These errors will be described in the
next section.
Reversal errors in autistic signing
In the first linguistic studies of native-signing children with autism,
Shield (2010) and Shield and Meier (2012) found palm orientation and move-
ment reversals in the signing of such children. In a series of experiments,
they observed 10 native-signing children (nine deaf children and one hearing
child of deaf parents, or CODA; ages 4;7–16;3) who had been diagnosed with
an ASD. Naturalistic observation revealed that three of the younger children
produced numerous articulatory errors in interaction with their teachers or
parents, particularly reversals in palm orientation from inward to outward,
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 103
2639_Ch04.indd 1032639_Ch04.indd 103 05-12-2013 18:40:2705-12-2013 18:40:27

and vice versa. Shield also performed a series of experiments designed to elicit
lexical signs and ASL-like nonsense signs that could lead to perspective-
taking reversal errors. Although the small sample size did not yield results of
great statistical power, Shield found that four of the younger children (all
under the age of 10) produced inward-outward palm reversals in elicited
fingerspelling, spontaneous and elicited lexical signs, and imitated nonsense
signs. These types of palm orientation reversals do not appear to occur fre-
quently in the typical acquisition of signed languages by deaf children.
Of the experimental tasks, the fingerspelling task (reported in Shield &
Meier, 2012) yielded the most robust results. This task consisted of showing
children a series of 10 English words (bed, table, watch, telephone, cap, chair, door,
shoes, book and scissors) on cards and asking them to fingerspell those words.
Three out of four young ASD subjects showed a robust tendency to finger-
spell with an inward palm orientation, despite the fact that fingerspelling in
ASL is in general articulated with an outward orientation. One child (age 5;8)
reversed 20 of 28 fingerspelled letters (71%), another child (age 6;6) reversed
26 of 43 fingerspelled letters (61%), and the third child (age 7;5) reversed 27
of 57 fingerspelled letters (47%). A search of the literature on the acquisition
of the fingerspelling system of ASL ( Padden, 1991, 2006; Padden & Lemaster,
1985) found no reports of such errors. None of the 13 TD deaf children in the
control group produced any fingerspellings with reversed palm orientation.
Shield and Meier considered whether the source of the palm orientation
errors observed could be purely articulatory (i.e. whether the errors could be
attributed to a physiological rather than a perceptual deficit). However, the
subjects produced fewer errors on the handshape parameter, which is typi-
cally mastered latest in development (Cheek et al., 2001; Clibbens & Harris,
1993; Karnopp, 1997; Marentette & Mayberry, 2000; Meier, 2006; Siedlecki
& Bonvillian, 1993; Takkinen, 2003; von Tetzchner, 1984), than on the palm
orientation and movement parameters. Moreover, in naturalistic observation
and in lexical elicitation these same children also produced outward palm
104 Part 1: Developmental Language Disorders in the Signed Modality
Figure 4.1 The ASL signs TUESDAY (left) and TOILET (right)
2639_Ch04.indd 1042639_Ch04.indd 104 05-12-2013 18:40:2705-12-2013 18:40:27

orientation reversals on signs specified for inward palm orientation (e.g. ASL
BUTTERFLY), demonstrating that the children were capable of producing
outward palm orientations. Finally, these errors are unlike those found in
disorders of neuromotor control: the only palm orientation errors observed
in, for example, Parkinsonian signers involved the substitution of a neutral
palm orientation toward the midline for an upward/downward palm orien-
tation (Brentari et al., 1995). Nor have inward-outward palm substitutions
been found in reports of sign language paraphasias: Chiarello et al. (1982)
reported two orientation errors in a signer with a left-hemisphere lesion,
both involving substitution of an orientation toward the midline for an
inward-facing orientation. It thus appears unlikely that motor difficulties
could be the sole source of these errors.
The palm orientation errors produced by deaf signing children with
autism are striking for a number of reasons: they are virtually unattested in
the literature on the typical acquisition of signed languages past 18 months
of age, they do not appear to be the result of articulatory difficulty, and they
are suggestive of a self-other mapping error. These errors, therefore, have the
potential to shed light on the cognitive processes of the autistic child in
learning to represent signs mentally, although more work needs to be done
in order to identify the individual cognitive processes involved. On a clinical
note, these errors may serve as a marker of autism in signing children.
While the role of perspective-taking is most obvious in deictic construc-
tions in spoken languages, it impacts the structure and acquisition of signed
languages at many levels. Shield and Meier found reversal errors at the sub-
lexical level, as described above, but Morgan et al. also found reversal errors
in verb agreement and spatial classifier constructions in the signing of
Christopher. Despite his abilities in learning other morphosyntactic con-
structions, Christopher had persistent problems in producing the correct
direction of movement on inflecting verbs (such as HELP in British Sign
Language) that change direction depending on their argument structure: in
trying to copy his teacher’s signing of ‘you help me’, Christopher produced
the equivalent of ‘I help you’, reversing the direction of movement (Morgan
et al., 2002a). It is not clear, however, whether Christopher reversed the direc-
tion of movement so as to preserve the semantics of the phrase or because of
a perceptually based error (a failure to shift perspectives). Shield and Meier
did not test verbs in their study, so it remains to be seen whether native-
signing deaf children with autism have difficulty with verbs in which the
direction of movement changes depending on their argument structure.
Returning to the earlier discussion of pronoun reversals, we now have
reason to hypothesize that pronoun reversals may not occur frequently in
the signing of autistic children, or at least not for the same reasons they
occur in speech. Why would children who have a deficit in self-other map-
ping not reverse sign pronouns? Reversing pronouns in speech entails repeat-
ing pronouns exactly as they are spoken to the child: the child repeats ‘you’
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 105
2639_Ch04.indd 1052639_Ch04.indd 105 05-12-2013 18:40:2805-12-2013 18:40:28

as spoken by their conversation partner, failing to change the pronoun to ‘I’
or ‘me’. Yet the studies on gesture imitation and lexical phonology discussed
above suggest that children with autism sometimes do not reproduce signs
exactly as produced by their conversational partners, but instead reproduce
signs as observed from their own perspective. This could lead the signing
autistic child to reproduce the pronoun YOU addressed to him as ME – in
other words, the correct pronoun. Although more research is needed to test
this hypothesis, the available evidence suggests that the deficit underlying
pronoun reversals in autistic speech may manifest in sign language as palm
orientation and movement reversals, rather than pronominal reversals per se.
This may be a possible difference in the linguistic manifestations of autism
in sign and speech.
We have thus demonstrated how two of the hallmarks of autistic
speech – echolalia and pronoun reversal – manifest in autistic signing.
Echolalia appears to be modality independent, insofar as there is already
evidence from several different studies that signing children with autism
produce echolalic signed utterances, much like hearing children with autism
do in speech. However, at the time of this writing there is no evidence of
pronoun reversals in the signing of children with autism. There is ample
evidence in the literature for palm and movement reversals in gesture imita-
tion by hearing and deaf children with autism, and for palm reversals in the
spontaneous and elicited signing and fingerspelling of native-signing chil-
dren with autism. These errors are suggestive of a deficit in understanding
the relationship between self and other as it is embodied and reflected
in language.
Joint attention, eye gaze and facial grammar
One of the most interesting aspects of sign language acquisition that is
likely to be affected by ASD is facial grammar. In this section, we will dis-
cuss the linguistic consequences for signed languages of autistic deficits in
eye gaze, attention and face processing. We will then proceed to a discussion
of facial grammar – the encoding of linguistic information on the face in
signed languages – and discuss recent work testing the abilities of autistic
signers in this area.
Children with autism are impaired in the ability to engage in dyadic
interactions (Leekam & Ramsden, 2006), resulting in fewer episodes of joint
attention (Curcio, 1978; Loveland & Landry, 1986; Mundy et al., 1986;
Sigman et al., 1999). Joint attention is positively associated with language
development (Charman et al., 2003) and is thought to be a fundamental
building block in the acquisition of word meanings (Tomasello & Farrar,
1986). Such an impairment could reflect a general deficit in the ability to orient
to social as opposed to non-social stimuli (Dawson et al., 1998; Leekam &
Ramsden, 2006; Leekam et al., 2000). Here we encounter an interesting
106 Part 1: Development al Language Disorders in the Signed Modalit y
2639_Ch04.indd 1062639_Ch04.indd 106 05-12-2013 18:40:2805-12-2013 18:40:28

difference between sign and speech: in sign the linguistic stimulus cannot be
isolated and separated from the person producing it, while in speech the
linguistic stimulus can in fact be perceived without attending to the person
producing it. In other words, hearing children with autism can perceive
speech without looking at the person speaking, whereas deaf children with
autism cannot perceive sign without looking (at least peripherally) at the
person signing.
The implications of communicating in the visual modality are broad.
Deaf children with autism may face challenges in learning the meanings of
signs. Bloom (e.g. Bloom, 2002) has shown that hearing children’s ability to
learn words is related to an ability to follow other people’s gaze, and thus
understand the referential intent of their interlocutor. For example, if a child
is looking at an object and an adult simultaneously utters a label, a TD child
will consult the adult’s gaze to confirm that the adult intended to label the
object in the child’s gaze, and not a different object. In other words, children
are more likely to make mappings between words and objects when they
are able to infer that the people uttering these words intend to refer to such
objects (Baldwin et al., 1996; Bloom, 2002). Yet children with autism do not
appear to learn words like TD children. In one study (Baron-Cohen et al.,
1997a), children with autism were tested to see if they consulted a speaker’s
direction of gaze in word-object mappings. They found that TD children
only learned to associate a word with an object if the speaker looked at the
object in question while labeling it. Children with autism, on the other
hand, made significantly more mapping errors when the speaker’s gaze was
discrepant with the label, showing that unlike normal children, they were
relatively insensitive to a speaker’s gaze direction as an index of the inten-
tion to refer.
We expect that deaf children with autism will make similar mapping
errors in the learning of sign labels for objects. However, to date there have
been no studies testing this hypothesis. Furthermore, there could be interest-
ing differences between deaf and hearing children with autism since sign
labels are unimodal (a visual linguistic stimulus is mapped to a visual object)
while spoken labels are intermodal (an acoustic linguistic stimulus is mapped
to a visual object). This represents a fruitful area for future research.
The autistic impairment in joint attention and in the gauging of referen-
tial intent has implications for the learning of symbols in both sign and
speech. However, a deficit in face processing has unique linguistic conse-
quences in sign (although it may also disrupt the comprehension of pragmatic
aspects of speech). Signed languages encode a variety of grammatical struc-
tures on the face, including questions (Baker, 1983), relative clauses (Liddell,
1980), conditionals (Liddell, 1986), topics (Coulter, 1979), and adverbial and
lexical information (Anderson & Reilly, 1999; Liddell, 1980). A number of
studies have shown that skilled deaf signers fixate on the face rather than the
hands while perceiving sign language (e.g. Agrafiotis et al., 2006).
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 107
2639_Ch04.indd 1072639_Ch04.indd 107 05-12-2013 18:40:2805-12-2013 18:40:28

Yet children with autism have documented deficits in attending to and
recognizing information from the face (Dawson et al., 2005; Klin et al., 1999;
Schultz et al., 2003), as well as deficits in the comprehension (Baron-Cohen
et al., 1993; Capps et al., 1992; Grossman & Tager-Flusberg, 2008; Lacroix et al.,
2009; Rump et al., 2009) and imitation (e.g. Hertzig et al., 1989; Loveland et al.,
1994) of affective facial expressions. Several research studies have shown that
the face scanning behavior of autistic individuals differs from that of non-
autistic individuals (Dalton et al., 2005; Klin et al., 2002; Pelphrey et al., 2002).
Pelphrey et al. (2002) compared the visual scan paths of autistic adults and
non-autistic controls, finding that the scan paths of the autistic group were
undirected whereas the scan paths of control subjects focused on a triangle
between the eyes, nose and mouth.
Several other studies of face gaze by hearing autistic subjects are sugges-
tive of how deaf children with autism may process facial grammar. Joseph
and Tanaka (2003) tested autistic and TD subjects’ ability to recognize facial
features that were presented in isolation or in an image of the whole face.
Only the TD group showed a whole-face advantage, whereas the autism
group demonstrated a mouth advantage and was impaired in recognizing the
eyes. Other studies have reported similar findings: Spezio et al. (2007) com-
pared nine high-functioning adults with autism to IQ-matched controls on
face gaze behavior and found that the autistic adults relied on information
from the mouth region while neglecting the eye region. Finally, Baron-Cohen
et al. (1997b) analyzed autistic recognition of basic emotions and complex
mental states based on whether subjects were shown pictures of whole faces,
the eyes alone or the mouth alone. When compared to normal subjects,
adults with Asperger’s syndrome showed a significant impairment in recog-
nizing complex mental states (such as scheme or distrust), particularly in the
eyes-alone condition, indicating a difficulty in interpreting facial expressions
signaled by the eyes.
These impairments pose a unique problem for the deaf child with autism
acquiring sign, since the eyes and mouth sometimes encode different linguis-
tic information (Sandler, 2009; Wilbur, 2000). For example, in ASL the mouth
can encode lexical information (as in the sign NOT-YET, which is differenti-
ated from the sign LATE by a mouth movement alone), adverbial information
(e.g. a protruding tongue accompanied by exhalation ‘THH’ indicates care-
lessness when produced w ith a verb; Liddel l, 1978), and adjectival information
(e.g. puffed cheeks to indicate large size). The eye region is key for the signal-
ing of questions (with raised or furrowed eyebrows), topicalized noun phrases,
and conditionals. If deaf children with autism are impaired in their ability to
gain/process information from the eye region but not the mouth, then this
could differentially impact linguistic structures encoded in the eye region.
There is still relatively little work examining the eye gaze or facial pro-
cessing ability of deaf people with autism. The study by Poizner et al. (1987 )
reported that Judith M. stopped making eye contact at the age of 11 months,
108 Part 1: Development al Language Disorders in the Signed Modalit y
2639_Ch04.indd 1082639_Ch04.indd 108 05-12-2013 18:40:2805-12-2013 18:40:28

did not vary her facial expressions and did not respond to the facial expres-
sions of others. Smith et al. (2011) reported that Christopher initial ly avoided
eye contact with his conversational partner while learning BSL, although he
soon overcame his reluctance. He also did not produce appropriate question
facial markers during the repetition or spontaneous production of question
sentences. Based on these few reports, and given the wide variability found
in the severity and symptoms of autism, it appears likely that there will be
wide variability among deaf children with autism in terms of their ability to
make eye contact, to infer referential intent through the following of gaze,
and to comprehend and produce grammatical and affective facial expres-
sions. It is also possible that sign language exposure could help mitigate some
of the face processing deficit in autism, as deaf signing children and hearing
signing adults have both been found to have a face processing advantage
compared to non-signers on the Benton Facial Recognition Test (Bellugi et al.,
1990; Bettger, 1992).
In Shield’s (2010) interviews with Deaf mothers of deaf children with
autism, the mothers reported that their children were able to comprehend
non-manual markers but were limited in their ability to produce grammati-
cal facial markings. One mother remarked:
I don’t see a lot of facial expressions in [my autistic son], compared with
[my non-autistic son] .. . [My autistic son] is more expressionless when
he signs. He points to what he wants, just communication for basic
needs. He doesn’t elaborate his point with facial expressions ... I think he
can understand facial expressions, but he can’t express them. Does he
realize that facial expressions are an important part of communication?
I don’t know. [My non-autistic son] knows that, but for [my autistic
son], I don’t know. I’m not sure.
The mothers also reported a deficit in their children’s ability to produce facial
morphemes, such as the question-marking facial expression used for
Wh-questions:
On the WHY question, [my son] doesn’t produce the lowering eyebrows
and squinting eyes. No. Like the WHERE question, he doesn’t produce
the raising eyebrows and widening eyes.11 No.
These reports, although anecdotal, are interesting because they indicate that
facial grammar may be difficult for deaf children with autism, even those
with native exposure from birth.
Recent studies by Denmark and colleagues (Denmark, 2011; Denmark
et al., 2009) provide the only systematic data available on the use of the face
by deaf signers with autism. Denmark (2011) investigated deaf autistic sign-
ers’ face and emotion recognition abilities as well as their comprehension
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 109
2639_Ch04.indd 1092639_Ch04.indd 109 05-12-2013 18:40:2805-12-2013 18:40:28

and production of grammatical and affective facial markers in BSL. She
compared a group of 13 deaf children and adolescents with autism (age
range 8;5–18;0, M = 12;6) to a group of 12 TD deaf children (M = 11;8). The
groups were matched for chronological age, BSL proficiency and non-verbal
ability. Only one of the deaf subjects was a native signer with deaf parents.
She found that the deaf ASD signers showed a mixed profile of abilities;
however, overall they did not show characteristic impairment in their com-
prehension and production of linguistic and affective facial expression, as
might have been expected.
The deaf ASD group showed strengths in several areas. First, deaf ASD
subjects did not differ significantly from controls on the Benton Facial
Recognition Test (BFRT; Benton, 1983), unlike hearing autistic subjects who
demonstrate impaired performance on the BFRT. Second, on a task designed
to elicit emotional facial expressions, ASD subjects were only slightly worse
than controls at reproducing observed facial expressions, and there was no
statistical difference in the number of expressions produced by the two
groups, despite the fact that prior studies have shown that hearing children
with autism produce fewer facial expressions than TD hearing children
(Bieberich & Morgan, 1998; Muller & Schuler, 2006; Yirmiya et al., 1989) and
their facial expressions have also been judged as more unusual or odd than
those of controls (Macdonald et al., 1989; Volker et al., 2009). Third, on a task
designed to elicit linguistic and affective facial expressions, ASD signers were
not significantly impaired in the frequency with which they produced facial
expressions, although they were impaired in terms of quality, producing
fewer expressions that were judged by raters as identical to stimuli than the
control group. Fourth, on tasks designed to test comprehension and produc-
tion of negation and question facial expressions in BSL, the ASD group was
not impaired relative to controls on the comprehension or production of
either type of linguistic facial marker. As an explanation for these surprising
findings, Denmark suggested that the attention to faces needed to perceive
sign language forces attention to faces during development, leading to
improved facial recognition ability. On a related note, other studies have
found that native exposure to a sign language leads to enhanced visuospatial
abilities (cf. Bosworth & Dobkins, 2002).
The ASD group did show several weaknesses, however. On an emotion
recognition task, the deaf ASD group performed significantly worse than the
deaf control group. Denmark concluded that this finding suggests that deaf
ASD subjects glean less affective information from the face than deaf controls.
Furthermore, she hypothesized a connection to an autistic deficit in prosody
(Baltaxe & Guthrie, 1987; McCann & Peppé, 2003; Peppé et al., 2006; Tager-
Flusberg, 1981), since affective facial expressions produced during signing could
be akin to prosodic elements of speech (Dachkovsky & Sandler, 2009).
The second weakness Denmark found was on tasks designed to test the
comprehension and production of adverbial facial expressions. TD deaf
110 Part 1: Developmental L anguage Disorders in the Signed Modality
2639_Ch04.indd 1102639_Ch04.indd 110 05-12-2013 18:40:2805-12-2013 18:40:28

children were more accurate than the ASD group in comprehending adverbial
facial expressions. Furthermore, the ASD group was less accurate at compre-
hending adverbial facial expressions when unaccompanied by a manual sign.
On the production task, moreover, the ASD group produced fewer adverbial
facial actions than controls. Thus, Denmark concluded that deaf people with
autism may be specifically impaired in their ability to comprehend and pro-
duce adverbial facial markers. We would like to see more research that inves-
tigates this important topic.
Taken as a whole, Denmark’s study represents the first attempt to under-
stand how a known social deficit in autism – a deficit in face processing and
in the comprehension and production of facial expression – impacts specific
grammatical structures encoded on the face in a signed language. Surprisingly,
her studies did not find evidence of a primary impairment in face processing
that has linguistic effects on the use of facial expressions in BSL. Rather, she
argued that the pattern of spared and impaired abilities in deaf autistic sign-
ers can be explained by deficits in emotional understanding. However, we
must be cautious in generalizing from her findings. Only one of her subjects
was a native BSL signer. More importantly, her participants were far beyond
the typical age of acquisition for the various facial structures that were tested
(4:0 for negation, 5:0 for adverbials and 6:0 for questions in ASL; Mayberry &
Squires, 2006). More studies of younger subjects with autism will be needed
in order to understand how grammatical facial expressions develop. Finally,
her study only included children with high-functioning autism; five deaf
children with severe autism who had insufficient sign ing skills were excluded
from the study. Nevertheless, her surprising findings suggest that repeated
exposure to a sign language may counteract underlying social deficits in
autism and that at least some deaf children with autism are capable of acqui r-
ing facial grammar.
Conclusions and Future Directions
Research into the sign language development of children with autism is
still in its infancy. We have described initial investigations into this area
which, despite being suggestive of interesting interactions between autism
and communication using the visual-gestural modality, need to be confirmed
by future studies.
Although it is still too early to be able to make recommendations for
clinicians and school psychologists with much confidence, the studies cur-
rently available do suggest a few implications for clinical practice. First, the
finding of palm reversals in the signing of deaf children with ASD is a rare
occurrence of a ‘positive’ symptom of ASD – that is, the presence of a phe-
nomenon rather than the absence of a skill. As such, it may be particularly
useful for parents and clinicians alike in signaling a possible ASD. Secondly,
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 111
2639_Ch04.indd 1112639_Ch04.indd 111 05-12-2013 18:40:2805-12-2013 18:40:28

since perspective-taking appears to be problematic for children with ASD,
parents, teachers and clinicians may find it helpful to sit beside the child,
rather than opposite him or her, while signing or providing therapy to a deaf
child with ASD.
As for a future research agenda, we envision several major areas where
future research could be fruitful:
(1) Further research on facial grammar and eye gaze behavior, including
eye-tracking studies. Studies of younger subjects in particular are
needed. Such studies may depend on earlier identification of ASD in deaf
children.
(2) Further research on structures in sign language grammar that require
self-other mapping, including pronouns, verb agreement, classifier con-
structions and role shift. In particular, we currently cannot say whether
the pronoun reversals that are so typical of autistic speech are also found
in autistic signing.
(3) Research into the relation between non-linguistic cognitive skills, such
as theory of mind, inter-subjective identification and motor imitation,
and the acquisition and development of sign language structures.
(4) Longitudinal studies that document sign language development over
time. Such studies could help clarify the developmental trajectory of
language development in autism and the nature of developmental delay
in autism.
(5) Bilingual studies of hearing children exposed to sign language and speech
from birth (CODAs), which may be able to reveal important modality
differences between sign and speech development. In particular, we
believe that a study of pronoun use in a bilingual CODA with autism
may be of special interest, since pronoun reversals are so characteristic of
autistic speech but have yet to be documented in autistic signing.
The first goal of such a research agenda must be the documentation of
the comprehension and production skills of native and non-native signing
children. As we have argued in this chapter, the characteristics of autistic
signing will likely differ in certain key ways from the characteristics of autis-
tic speech. We cannot yet say with certainty whether all the hallmarks of
autistic speech will also be found in the signing of deaf children with autism.
Cross-linguistic studies into different signed languages will be helpful for
confirming phenomena that are general to the modality, or identifying lan-
guage-specific phenomena.
In the documentation process, several methodological considerations
must be carefully attended to. First, utmost care must be taken in the selec-
tion of subjects. The diagnosis of autism must be confirmed carefully using
appropriate instruments. However, as we have already pointed out, the lack
of sign language translations of the current gold standard instruments poses
112 Part 1: Developmental Language Disorders in the Signed Modality
2639_Ch04.indd 1122639_Ch04.indd 112 05-12-2013 18:40:2805-12-2013 18:40:28

a significant challenge to both clinicians and researchers. We thus suggest a
multifaceted approach, using the available screening and diagnostic instru-
ments with appropriate adaptations made for deaf children. It is crucial that
children be evaluated by clinicians who are familiar with deaf children and
are aware of the modality differences that exist between sign and speech, as
well as the different social norms of Deaf culture.
A related issue is the careful matching of ASD subjects to subjects w ith-
out ASD (both TD and with other developmental disorders). In particular,
subjects should be matched for chronological age, language age, and/or non-
verbal intelligence, depending on the research question.
Measures of motor ski lls should be taken in studies of autistic signing, so
as to properly identify whether errors observed have a perceptual or motor
origin. Ming et al. (2007) found various motor problems in a sample of 154
ASD children, including hypotonia (51%), motor apraxia (34%), toe-walking
(19%) and gross motor delay (9%). Since sign language entails both gross and
fine motor movements, such impairments are likely to impact how deaf chil-
dren on the spectrum acquire sign.
Once there is sufficient documentation of autistic signing, these studies
should be used in the adaptation of existing gold-standard diagnostic instru-
ments for use with deaf children (e.g. the ADOS and ADI-R), and the devel-
opment of appropriate sign language educational strategies and interventions.
The translation of diagnostic instruments into various signed languages will
in itself be a large undertaking, and will require careful consideration of dif-
ferences between the visual-gestural and vocal-auditory modalities, as well
as the heterogeneity of the deaf population (i.e. age of exposure to language,
sign versus oral speech training, amplification and cochlear implantation,
comorbidities, etc.).
Research into sign language development of deaf children on the autism
spectrum has the potential to shed l ight on issues of i nterest well beyond the
community of scientists who work on signed languages. In particular, in
observing language acquisition in the visual-gestural modality, there is an
opportunity to test hypotheses about the nature of the autistic phenotype
and the core cognitive mechanisms underlying autistic impairments. Signed
languages rely crucially on a set of social skills known to be impaired in
autism, and careful study of deaf children on the spectrum could clarify the
nature of cognitive deficits in autism, as well as the relationship between
social skills and language development. Thus, despite the considerable meth-
odological difficulties that we have highlighted, we hope that researchers
will feel encouraged to pursue studies in this area. We believe that such
research is feasible (albeit methodologically complex), and could benefit deaf
and hearing children on the autism spectrum, as well as the Deaf commu-
nity, the scientific community and society at large, by contributing insights
about the nature of autism, and its complicated effects on cognition and
language.
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 113
2639_Ch04.indd 1132639_Ch04.indd 113 05-12-2013 18:40:2805-12-2013 18:40:28

Notes
(1) Until DSM-5, subcategories of ASD included autistic disorder, Asperger’s disorder,
and pervasive developmental disorder-not otherwise specified (PDD-NOS).
(2) Although he lacks an official diagnosis, the authors cite Christopher’s aversion to
eye contact and social interaction as well as his consistent failure on false-belief
tasks as evidence of his autism.
(3) Seal and Bonvillian did not examine palm orientation as a separate parameter.
(4) We use the term ‘echolalia’ (the automatic imitation of the vocalizations of others)
here rather than ‘echopraxia’ (the involuntary imitation of the body movements of
others) because of the linguistic nature of the signs being imitated. Both echolalia
and echopraxia have been documented in hearing autistic children.
(5) Note that Poizner et al. translated the father’s ASL signing into English. Thus,
despite the translation, there would have been no indefinite article in this first
sentence. Consequently Judith appears to have echoed the last two signs of her
father’s utterance verbatim.
(6) To our knowledge, there is no report of whether or not Christopher was echolalic in
his production of spoken languages.
(7) It is unclear whether this example is truly an instance of verb reversal or merely an
uninflected citation form of the verb give. Indeed, homonymy or near-homonymy
of citation forms and 1st-to-2nd person inflected forms presents a serious method-
ological problem in detecting verb agreement reversals in sign.
(8) A name sign is a sign that is used to uniquely identify a person, like a name.
(9) Translated from ASL to English by Lynn Hou.
(10) Some authors have argued that the mirror neuron system of the brain, through
which children match their movements to those observed in others, is impaired in
ASD (cf. Dapretto et al., 2005; Iacoboni & Dapretto, 2006).
(11) Note that this mother’s description of the facial marking for the ASL question word
where conflicts with the standard facial marking reported in the literature
(Baker, 1983; Baker-Shenk & Cokely, 1991).
References
Agrafiotis, D., Canagarajah, N., Bull, D.R., Kyle, J., Seers, H. and Dye, M. (2006) A per-
ceptually optimised video coding system for sign language communication at low bit
rates. Signal Processing: Image Communication 21, 531–549.
Anderson, D. and Reilly, J. (1999) PAH! The acquisition of non-manual adverbials in ASL.
Sign Language and Linguistics 1, 115–142.
Attwood, A., Frith, U. and Hermelin, B. (1988) The understanding and use of interper-
sonal gestures by autistic and Down’s syndrome children. Journal of Autism and
Developmental Disorders 18, 241–257.
Baker, C.L. (1983) A microanalysis of the nonmanual components of questions in
American Sign Language. Understanding Language Through Sign Language Research (pp.
27–57). New York: Academic Press.
Baker-Shenk, C.L . and Cokely, D. (1991) American Sign Language: A Teacher’s Resource Text
on Grammar and Culture. Washington, DC: Gallaudet University Press.
Baldwin, D.A., Markman, E.M., Bill, B., Desjardins, R.N., Irwin, J.M. and Tidball, G.
(1996) Infants’ reliance on a social criterion for establishing word-object relations.
Child Development 67, 3135–3153.
Baltaxe, C.A. and Guthrie, D. (1987) The use of primary sentence stress by normal,
aphasic, and autistic children. Journal of Autism and Developmental Disorders 17,
255–271.
114 Part 1: Developmental L anguage Disorders in the Signed Modality
2639_Ch04.indd 1142639_Ch04.indd 114 05-12-2013 18:40:2805-12-2013 18:40:28

Baron-Cohen, S. (1989) Perceptual role taking and protodeclarative pointing in autism.
British Journal of Developmental Psychology 7, 113 – 1 2 7.
Baron-Cohen, S., Spitz, A. and Cross, P. (1993) Do children with autism recognise sur-
prise? A research note. Cognition & Emotion 7, 5 07– 516 .
Baron-Cohen, S., Baldwin, D.A. and Crowson, M. (1997a) Do children with autism use
the speaker’s direction of gaze strategy to crack the code of language? Child
Development 68, 48–57.
Baron-Cohen, S., Wheelwright, S. and Jolliffe, T. (1997b) Is there a ‘language of the eyes’?
Evidence from normal adults, and adults with autism or Asperger syndrome. Visual
Cognition 4, 311–331.
Bartak, L. and Rutter, M. (1974) The use of personal pronouns by autistic children. Journal
of Autism and Developmental Disorders 4, 217–222.
Bellugi, U., O’Grady, L., Lillo-Martin, D., O’Grady, M., van Hoek, K. and Corina, D.
(1990) Enhancement of spatial cognition in deaf children. In V. Volterra and C. Erting
(eds) From Gesture to Language in Hearing and Deaf Children (pp. 278–298). Washington,
DC: Gallaudet University Press.
Benton, A.L., Sivan, A.B., Hamsher, K., Varney, N.R. and Spreen, O. (1983) Facial recogni-
tion: Stimulus and multiple choice pictures. In A.L. Benton, A.B. Sivan, K. Hamsher,
N.R. Varney and O. Spreen (eds) Contributions to Neuropsychological Assessment (pp.
35– 52). New York: Oxford University Press.
Bettger, J. (1992) The effects of experience on spatial cognition: Deafness and knowledge
of ASL. Unpublished doctoral dissertation, University of Illinois.
Bieberich, A.A. and Morgan, S.B. (1998) Brief report: Affective expression in children with
autism or Down syndrome. Journal of Autism and Developmental Disorders 28, 333–338.
Bloom, L. and Lahey, M. (1978) Language Development and Language Disorders. Somerset,
NJ: John Wiley & Sons.
Bloom, P. (2002) How Children Learn the Meanings of Words. Cambridge, MA: MIT Press.
Bondy, A.S. and Frost, L.A. (1994) The picture exchange communication system. Focus on
Autism and Other Developmental Disabilities 9, 1–19.
Bonvillian, J.D. and Blackburn, D.W. (1991) Manual communication and autism: Factors
relating to sign language acquisition. In P. Siple and S. Fischer (eds) Theoretical Issues
in Sign Language Research, Vol. 2: Psychology (pp. 255–277). Chicago, IL: University of
Chicago Press.
Bonvillian, J.D., Nelson, K.E. and Rhyne, J.M. (1981) Sign language and autism. Journal of
Autism and Developmental Disorders 11, 125–137.
Bosworth, R.G. and Dobkins, K.R. (2002) The effects of spatial attention on motion
processing in deaf signers, hearing signers and hearing non signers. Brain and Cognition
49, 152–169.
Brentari, D., Poizner, H. and Kegl, J. (1995) Aphasic and Parkinsonian signing: Differences
in phonological disruption. Brain and Language 48, 69–105.
Brimer, J. and Murphy, P. (1988) Autism and deafness: A case study of a deaf and autistic
boy. In H.T. Pricket and E. Duncan (eds) Coping with the Multi-handicapped Hearing
Impaired (pp. 37–44). Springfield, IL: Charles C. Thomas.
Brown, J.D. (1996) Imitation, play and theory of mind in autism: An observational and
experimental study. Unpublished doctoral dissertation, Saint Andrew’s University.
Buitelaar, J.K., van Engeland, H., de Kogel, K.H., de Vries, H. and van Hooff, J.A. (1991)
Differences in the structure of social behaviour of autistic children and non-autistic
retarded controls. Journal of Child Psychology and Psychiatry, and Allied Disciplines 32,
995–1015.
Capps, L., Yirmiya, N. and Sigman, M. (1992) Understanding of simple and complex
emotions in non-retarded children with autism. Journal of Child Psychology and
Psychiatry 33, 1169–1182.
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 115
2639_Ch04.indd 1152639_Ch04.indd 115 05-12-2013 18:40:2805-12-2013 18:40:28

Carr, E.G. (1979) Teaching autistic children to use sign language: Some research issues.
Journal of Autism and Developmental Disorders 9, 34 5 – 359.
Casey, S. (2003) Relationships between gestures and signed languages: Indicating partici-
pants in action. In A. Baker, B. van den Bogaerde and O. Crasborn (eds) Cross-linguistic
Perspectives in Sign Language Research: Selected Papers from TISLR 2000 (pp. 95 –117).
Hamburg: Signum.
Centers for Disease Control (2012) Prevalence of autism spectrum disorders – Autism and
Developmental Disabilities Monitoring Network, 14 sites, United States, 2008.
Morbidity and Mortality Weekly Report 61, 1–19.
Charman, T., Baron-Cohen, S., Swettenham, J., Baird, G., Drew, A. and Cox, A. (2003)
Predicting language outcome in infants with autism and pervasive developmental
disorder. International Journal of Language & Communication Disorders 38, 265 –285.
Charney, R. (1980) Pronoun errors in autistic children: Support for a social explanation.
International Journal of Language & Communication Disorders 15, 39–43.
Cheek, A., Cormier, K., Repp, A. and Meier, R.P. (2001) Prelinguistic gesture predicts
mastery and error in the production of early signs. Language 77, 292–323.
Che ss, S., Fer nandez, P. a nd Korn, S. (1978) Behav ioral consequenc es of congenit al rubella.
Journal of Pediatrics 93, 699–703.
Chiarello, C., Knight, R. and Mandel, M. (1982) Aphasia in a prelingually deaf woman.
Brain: A Journal of Neurology 105, 29.
Chiat, S. (1982) If I were you and you were me: The analysis of pronouns in a pronoun-
reversing child. Journal of Child Language 9, 3 59– 379.
Clark, E.V. (1978) From gesture to word: On the natural history of deixis in language
acq uisition. In J.S. Brune r and A . Gar ton (ed s) Human Growth and Development: Wolfson
College Lectures 1976 (pp. 85–120). Oxford: Oxford University Press.
Clibbens, J. and Harris, M. (1993) Phonological processes and sign language development.
In D. Messer and G. Turner (eds) Critical Influences on Child Language Acquisition and
Development (pp. 197–208). New York: Macmillan Press.
Collins, P. and Carney, S. (2007) Autism spectrum disorder, deafness and challenging
behaviour. In S. Austen and D. Jeffery (eds) Deafness and Challenging Behaviour: The
360 Perspective (pp. 125–143). Chichester: John Wiley & Sons.
Constantino, J.N. (2002) The Social Responsiveness Scale. Los Angeles, CA: Western
Psychological Services.
Coulter, G.R. (1979) American Sign Language typology. Unpublished doctoral disserta-
tion, University of California.
Creedon, M.P. (1973) Language development in nonverbal autistic children using a simul-
taneous communication system. Paper presented at the Society for Resarch in Child
Development Meeting, Philadelphia, PA.
Curcio, F. (1978) Sensorimotor functioning and communication in mute autistic children.
Journal of Autism and Developmental Disorders 8, 281–292.
Dachkovsky, S. and Sandler, W. (2009) Visual intonation in the prosody of a sign lan-
guage. Language and Speech 52, 287–314.
Dale, P.S. and Crain-Thoreson, C. (1993) Pronoun reversals: Who, when, and why? Journal
of Child Language 20, 573– 589.
Dalton, K.M., Nacewicz, B.M., Johnstone, T., Schaefer, H.S., Gernsbacher, M.A.,
Goldsmith, H., Alexander, A.L., et al. (2005) Gaze fixation and the neural circuitry
of face processing in autism. Nature Neuroscience 8, 519–526.
Dapretto, M., Davies, M.S., Pfeifer, J.H., Scott, A.A., Sigman, M., Bookheimer, S.Y. and
Iacoboni, M. (2005) Understanding emotions in others: Mirror neuron dysfunction
in children with autism spectrum disorders. Nature Neuroscience 9, 2 8 – 30.
Dawson, G. and Adams, A. (1984) Imitation and social responsiveness in autistic chil-
dren. Journal of Abnormal Child Psychology 12, 209–226.
116 Part 1: Developmental L anguage Disorders in the Signed Modality
2639_Ch04.indd 1162639_Ch04.indd 116 05-12-2013 18:40:2805-12-2013 18:40:28

Dawson, G., Meltzoff, A.N., Osterling, J., Rinaldi, J. and Brown, E. (1998) Children with
autism fail to orient to naturally occurring social stimuli. Journal of Autism and
Developmental Disorders 28, 479–485.
Dawson, G., Webb, S.J. and McPartland, J. (2005) Understanding the nature of face pro-
cessing impairment in autism: Insights from behavioral and electrophysiological
studies. Developmental Neuropsychology 27, 403–424.
DeMyer, M.K., Alpern, G.D., Barton, S., DeMyer, W.E., Churchill, D.W., Hingtgen, J.N.,
Bryson, C.Q., et al. (1972) Imitation in autistic, early schizophrenic, and non-psy-
chotic subnormal children. Journal of Autism and Developmental Disorders 2,
264–287.
Den mark, T. (2011) Do de af child ren with Autism Spectrum Disorder show deficits in the
comprehension and production of emotional and linguistic facial expressions in British
Sign Language? Unpublished doctoral dissertation, University College London.
Denmark, T., Swettenham, J., Atkinson, J. and Campbell, R. (2009) What’s in the face?
The comprehension and production of facial expressions in sign language by deaf
children with autism. Poster presented at the International Meeting for Autism
Research (IMFAR), Chicago, IL.
Gallaudet Research Institute (2011) Regional and National Summary Report of Data from the
2009–2010 Annual Survey of Deaf and Hard of Hearing Children and Youth. Washington,
DC: GRI, Gallaudet University.
Gilliam, J.E. (2006) Gilliam Autism Rating Scale – (2nd edn). Austin, TX: Pro-Ed.
Grossman, R.B. and Tager-Flusberg, H. (2008) Reading faces for information about words
and emotions in adolescents with autism. Research in Autism Spectrum Disorders 2,
681–695.
Hamilton, A., Brindley, R. and Frith, U. (2009) Visual perspective taking impairment in
children with autistic spectrum disorder. Cognition 113 , 37– 4 4.
Hat zopoulou, M . (2010) Ac quisition of reference to self and others i n Greek Sig n La nguage
(Stockholm University, 2008). Sign Language & Linguistics 13, 83–91.
Hertzig, M.E., Snow, M.E. and Sherman, M. (1989) Affect and cognition in autism.
Journal of the American Academy of Child & Adolescent Psychiatry 28, 195.
Hobson, R.P. and Lee, A. (1999) Imitation and identification in autism. Journal of Child
Psychology and Psychiatry 40, 649–659.
Hobson, R.P., García-Pérez, R.M. and Lee, A. (2010) Person-centred (deictic) expressions
and autism. Journal of Autism and Developmental Disorders 40, 403–415.
Iacoboni, M. and Dapretto, M. (2006) The mirror neuron system and the consequences
of its dysfunction. Nature Reviews Neuroscience 7, 942 – 951.
Jordan, R. (1990) Signing and autistic children. Communication 19, 9–12.
Joseph, R.M. and Tanaka, J. (2003) Holistic and part-based face recognition in children
with autism. Journal of Child Psychology and Psychiatry 44, 529–542.
Jure, R., Rapin, I. and Tuchman, R. (1991) Hearing-impaired autistic children.
Developmental Medicine and Child Neurology 33, 1062–1072.
Kanner, L. (1943) Autistic disturbances of affective contact. Nervous Child 2, 217–250.
Karnopp, L.B. (1997) Phonological acquisition in sign languages. Letras de Hoje 32, 147–162.
Klin, A., Sparrow, S.S., de Bildt, A., Cicchetti, D.V., Cohen, D.J. and Volkmar, F.R. (1999)
A normed study of face recognition in autism and related disorders. Journal of Autism
and Developmental Disorders 29, 499– 508.
Klin, A., Jones, W., Schultz, R., Volkmar, F. and Cohen, D. (2002) Visual fixation patterns
during viewing of naturalistic social situations as predictors of social competence in
individuals with autism. Archives of General Psychiatry 59, 809–816.
Lacroix, A., Guidetti, M., Rogé, B. and Reilly, J. (2009) Recognition of emotional and
nonemotional facial expressions: A comparison between Williams syndrome and
autism. Research in Developmental Disabilities 30, 976–985.
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 117
2639_Ch04.indd 1172639_Ch04.indd 117 05-12-2013 18:40:2805-12-2013 18:40:28

Lee, A., Hobson, R.P. and Chiat, S. (1994) I, you, me, and autism: An experimental study.
Journal of Autism and Developmental Disorders 24, 155–176.
Leekam, S.R. and Ramsden, C.A. (2006) Dyadic orienting and joint attention in pre-
school children with autism. Journal of Autism and Developmental Disorders 36,
185 –197.
Leekam, S.R., Lopez, B. and Moore, C. (2000) Attention and joint attention in preschool
children with autism. Developmental Psychology 36, 261–273.
Liddell, S.K. (1978) Nonmanual signals and relative clauses in American Sign Language.
In P. Siple (ed.) Understanding Language Through Sign Language Research (pp. 59–90).
San Diego, CA: Academic Press.
Liddell, S.K. (1980) American Sign Language Syntax. The Hague: Mouton.
Liddell, S.K. (1986) Head thrust in ASL conditional marking. Sign Language Studies 52,
243–62.
Lord, C., Rutter, M. and Le Couteur, A. (1994) Autism Diagnostic Interview – Revised: A
revised version of a diagnostic interview for caregivers of individuals with possible
pervasive developmental disorders. Journal of Autism and Developmental Disorders 24,
659–685.
Lord, C., Rutter, M., DiLavore, P.C., Risi, S., Gotham, K., and Bishop, S.L. (2012) Autism
Diagnostic Observation Schedule, Second Edition (ADOS-2). Torrance, CA: Western
Psychological Services.
Loveland, K.A. (1984) Learning about points of view: Spatial perspective and the acquisi-
tion of I/you. Journal of Child Language 11, 535–556.
Loveland, K.A. and Landry, S.H. (1986) Joint attention and language in autism and
developmental language delay. Journal of Autism and Developmental Disorders 16,
335–349.
Loveland, K.A., Tunali-Kotoski, B., Pearson, D.A., Brelsford, K.A., Ortegon, J. and Chen,
R. (1994) Imitation and expression of facial affect in autism. Development and
Psychopathology 6, 433–444.
Macdonald, H., Rutter, M., Howlin, P., Rios, P., Conteur, A.L., Evered, C. and Folstein, S.
(1989) Recognition and expression of emotional cues by autistic and normal adults.
Journal of Child Psychology & Psychiatry 30, 865– 877.
Malandraki, G.A. and Okalidou, A. (2007) The application of PECS in a deaf child with
autism: A case study. Focus on Autism & Other Developmental Disabilities 22, 23–32.
Mandell, D.S., Novak, M.M. and Zubritsky, C.D. (2005) Factors associated with age of
diagnosis among children with autism spectrum disorders. Pediatrics 116, 148 0 –1486 .
Marentette, P.F. and Mayberry, R.I. (2000) Principles for an emerging phonological system:
A case study of early A SL acquisition. In C. Chamberlai n, J.P. Morford and R.I. Mayberry
(eds) Language Acquisition by Eye (pp. 71–90). Mahwah, NJ: Lawrence Erlbaum.
Mayberry, R. and Squires, B. (2006) Sign language acquisition: Language acquisition. In
K. Brown (ed.) Encyclopedia of Language and Linguistics (2nd edn) (pp. 291–296).
Oxford: Elsevier.
McCann, J. and Peppe, S. (2003) Prosody in autism spectrum disorders: A critical review.
International Journal of Language & Communication Disorders 38, 325–350.
Meier, R.P. (2006) The form of early signs: Explaining signing children’s articulatory
development. In B. Schick, M. Marschark and P.E. Spencer (eds) Advances in the Sign
Language Development of Deaf Children (pp. 202–230). New York: Oxford University
Press.
Ming, X., Brimacombe, M. and Wagner, G.C. (2007) Prevalence of motor impairment in
autism spectrum disorders. Brain and Development 29, 565–570.
Mitchell, R.E. and Karchmer, M.A. (2004) Chasing the mythical ten percent: Parental
hearing status of deaf and hard of hearing students in the United States. Sign Language
Studies 4, 138–163.
118 Part 1: Developmental Language Disorders in the Signed Modality
2639_Ch04.indd 1182639_Ch04.indd 118 05-12-2013 18:40:2805-12-2013 18:40:28

Morgan, G., Smith, N., Tsimpli, I. and Woll, B. (2002a) Language against the odds: The
lea rning of British Sign L anguage by a polyglot savant. Journal of Linguistics 38, 1–41.
Morgan, G.D., Woll, B., Tsimpli, I. and Smith, N.V. (2002b) The effects of modality on
BSL development in an exceptional learner. In R.P. Meier, D. Quinto-Pozos and K.
Cormier (eds) Modality and Structure in Signed and Spoken Language (pp. 422– 441).
Cambridge: Cambridge University Press.
Morgan, G., Smith, N., Tsimpli, I. and Woll, B. (2007) Classifier learning and modality in
a polyglot savant. Lingua 117, 1339 –135 3.
Morgan, S.B., Cutrer, P.S., Coplin, J.W. and Rodrigue, J.R. (1989) Do autistic children
differ from retarded and normal children in Piagetian sensorimotor functioning.
Journal of Child Psychology and Psychiatry 30, 857–864.
Muller, E. and Schuler, A. (2006) Verbal marking of affect by children with Asperger
syndrome and high functioning autism during spontaneous interactions with family
members. Journal of Autism and Developmental Disorders 36, 1089 –1100.
Mundy, P., Sigman, M., Ungerer, J. and Sherman, T. (1986) Defining the social deficits of
autism: The contribution on non-verbal communication measures. Journal of Child
Psychology & Psychiatry & Allied Disciplines 27, 657–669.
Mundy, P., Sigman, M., Ungerer, J. and Sherman, T. (1987) Nonverbal communication
and play correlates of language development in autistic children. Journal of Autism and
Developmental Disorders 17, 349–364.
Ohta, M. (1987) Cognitive disorders of infantile autism: A study employing the WISC,
spatial relationship conceptualization, and gesture imitations. Journal of Autism and
Developmental Disorders 17, 45–62.
Ornitz, E.M. and Ritvo, E.R. (1976) The syndrome of autism: A critical review. American
Journal of Psychiatry 133, 609– 621.
Oshima-Takane, Y. (1992) Analysis of pronominal errors: A case-study. Journal of Child
Language 19, 111–131.
Oshima-Takane, Y., Cole, E. and Yaremko, R.L. (1993) Semantic pronominal confusion
in a hearing-impaired child: A case study. First Language 13, 149–168.
Padden, C.A. (1991) The acquisition of fingerspelling by deaf children. In P. Siple and S.D.
Fischer (eds) Theoretical Issues in Sign Language Research, Vol. 2: Psychology (pp. 191–
210). Chicago, IL: University of Chicago Press.
Padden, C.A. (2006) Learning to fingerspell twice: Young signing children’s acquisition
of fingerspelling. In B. Schick, M. Marschark and P.E. Spencer (eds) Advances in the
Sign Language Development of Deaf Children (pp. 189–201). New York: Oxford
University Press.
Padden, C. and Lemaster, B. (1985) An alphabet on hand: The acquisition of fingerspelling
in deaf children. Sign Language Studies 14, 161–172.
Pelphrey, K.A., Sasson, N.J., Reznick, J.S., Paul, G., Goldman, B.D. and Piven, J. (2002)
Visual scanning of faces in autism. Journal of Autism and Developmental Disorders 32,
249–261.
Peppé, S., McCann, J., Gibbon, F., O’Hare, A. and Rutherford, M. (2006) Assessing pro-
sodic and pragmatic ability in children with high-functioning autism. Journal of
Pragmatics 38, 1776–1791.
Peter s, A.M. (1983) The Units of Language Acquisition. Cambridge: Cambridge University Press.
Petitto, L. A. (19 87) On the autonomy of language and gesture: Ev idence from the acquisi-
tion of personal pronouns in American Sign Language. Cognition 27, 1–52.
Pizer, G., Meier, R.P. and Shaw Points, K. (2011) Child-directed signing as a linguistic
register. In R. Channon and H. van der Hulst (eds) Formational Units in Sign Languages
(pp. 65–86). Boston, MA: Walter de Gruyter.
Poizner, H., Klima, E.S. and Bellugi, U. (1990) What the Hands Reveal About the Brain.
Cambridge, MA: MIT Press.
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 119
2639_Ch04.indd 1192639_Ch04.indd 119 05-12-2013 18:40:2805-12-2013 18:40:28

Prizant, B.M. (1983) Language acquisition and communicative behavior in autism:
Toward an understanding of the ‘whole’ of it. Journal of Speech and Hearing Disorders
48, 296–307.
Prizant, B.M. and Duchan, J.F. (1981) The functions of immediate echolalia in autistic
children. Journal of Speech and Hearing Disorders 46, 241–249.
Reed, T. (2002) Visual perspective taking as a measure of working memory in participants
with autism. Journal of Developmental and Physical Disabilities 14, 63–76.
Ricard, M., Girouard, P.C. and Gouin Décarie, T. (1999) Personal pronouns and perspec-
tive taking in toddlers. Journal of Child Language 26, 681–697.
Ricks, D.M. and Wing, L. (1975) Language, communication, and the use of symbols in
normal and autistic children. Journal of Autism and Developmental Disorders 5,
191–221.
Rogers, S.J. and Pennington, B.F. (1991) A theoretical approach to the deficits in infantile
autism. Development and Psychopathology 3, 137–162.
Roper, L., Arnold, P. and Monteiro, B. (2003) Co-occurrence of autism and deafness:
Diagnostic considerations. Autism 7, 2 4 5– 25 3 .
Rosenhall, U., Nordin, V., Sandström, M., Ahlsén, G. and Gillberg, C. (1999) Autism and
hearing loss. Journal of Autism and Developmental Disorders 29, 349–357.
Rump, K.M., Giovannelli, J.L., Minshew, N.J. and Strauss, M.S. (2009) The development
of emotion recognition in individuals with autism. Child Development 80,
143 4 –14 47.
Rutter, M., Bailey, A. and Lord, C. (2003) Social Communication Questionnaire. Los Angeles,
CA: Western Psychological Services.
Sandler, W. (2009) Symbiotic symbolization by hand and mouth in sign language.
Semiotica 2009, 241–275.
Schick, B., de Villiers, P., de Villiers, J. and Hoffmeister, R. (2007) Language and theory
of mind: A study of deaf children. Child Development 78, 376–396.
Schiff-Myers, N.B. (1983) From pronoun reversals to correct pronoun usage: A case
study of a normally developing child. Journal of Speech and Hearing Disorders 48,
394–402.
Schuler, A.L. and Prizant, B. (1985) Echolalia. In E. Schopler and G.B. Mesibov (eds)
Communication Problems in Autism (pp. 163–184). New York: Plenum Press.
Schultz, R.T., Grelotti, D.J., Klin, A., Kleinman, J., Van der Gaag, C., Marois, R. and
Skudlarski, P. (2003) The role of the fusiform face area in social cognition:
Implications for the pathobiology of autism. Philosophical Transactions of the Royal
Society of London. Series B: Biological Sciences 358, 415–427.
Seal, B.C. and Bonvillian, J.D. (1997) Sign language and motor functioning in students
with autistic disorder. Journal of Autism and Developmental Disorders 27, 437–466.
Shield, A. (2010) The signing of deaf children with autism: Lexical phonology and per-
spective-taking in the visual-spatial modality. Unpublished doctoral dissertation,
University of Texas at Austin.
Shield, A. (2012) Palm reversals are the pronoun reversals of sign language. Poster pre-
sented at the International Meeting for Autism Research, Toronto.
Shield, A. and Meier, R.P. (2012) Palm reversal errors in native-signing children with
autism. Journal of Communication Disorders 45, 439–454.
Siedlecki, T. and Bonvillian, J.D. (1993) Location, handshape, and movement: Young chil-
dren’s acquisition of the formational aspects of American Sign Language. Sign
Language Studies 78, 31–52.
Sigman, M., Ruskin, E., Arbelle, S., Corona, R., Dissanayake, C., Espinosa, M., Kim, N.,
et al. (199 9) Continuity and change in the social competence of ch ildren with autism ,
Down syndrome, and developmental delays. Monographs of the Society for Research in
Child Development 64, 1–114.
120 Part 1: Development al Language Disorders in the Signed Modalit y
2639_Ch04.indd 1202639_Ch04.indd 120 05-12-2013 18:40:2805-12-2013 18:40:28

Smith, I.M. and Bryson, S.E. (1994) Imitation and action in autism: A critical review.
Psychological Bulletin 116, 2 59–273.
Smith, I.M. and Bryson, S.E. (1998) Gesture imitation in autism, I: Nonsymbolic postures
and sequences. Cognitive Neuropsychology 15, 747–770.
Smith, N., Tsimpli, I., Morgan, G. and Woll, B. (2011) The Signs of a Savant: Language
Against the Odds. New York: Cambridge University Press.
Soorya, L.V. (2003) Evaluation of motor proficiency and apraxia in autism: Effects on sign
language acquisition. Unpublished doctoral dissertation, State University of New
Yor k .
Spezio, M.L ., Adolphs, R., Hurley, R.S.E. and Piven, J. (2007) Abnormal use of facial
information in high-functioning autism. Journal of Autism and Developmental Disorders
37, 929–939.
Stull, S., Edkins, C., Krause, M., McGavin, G., Brand, L.H. and Webster, C.D. (1979) Sign
language as a means of communicating with autistic and mentally handicapped chil-
dren. Child and Youth Care Forum 8, 143 –147.
Szymanski, C. (2010) Characteristics and symptomotology of autism in children who are
deaf and hard of hearing. Unpublished doctoral dissertation, Gallaudet University.
Szy manski, C. A., Brice , P.J., Lam, K.H. and Hotto, S.A. (2012) Deaf ch ildren with Autism
Spectrum Disorders. Journal of Autism and Developmental Disorders 42 (10), 2027–2037.
doi:10.1007/s10803-012-1452-9.
Tager-Flusberg, H. (1981) On the nature of linguistic functioning in early infantile autism.
Journal of Autism and Developmental Disorders 11, 45–56.
Tager-Flusberg, H. (1993) What language reveals about the understanding of minds in
children with autism. In S. Baron-Cohen, H. Tager-Flusberg and D.J. Cohen (eds)
Understanding Other Minds: Perspectives From Autism (pp. 138–157). Oxford: Oxford
University Press.
Tager-Flusberg, H. (1994) Dissociations in form and function in the acquisition of lan-
guage by autistic children. In H. Tager-Flusberg (ed.) Constraints on Language
Acquisition: Studies of Atypical Children (pp. 175–194). Hillsdale, NJ: Lawrence Erlbaum.
Tager-Flusberg, H. (2000) Understanding the language and communicative impairments
in autism. In L.M. Glidden (ed.) International Review of Research on Mental Retardation:
Autism (Vol. 23). New York: Academic Press.
Takkinen, R. (2003) Variation of handshape features in the acquisition process. In A.
Baker, B. van den Bogaerde and O. Crasborn (eds) Cross-linguistic Perspectives in Sign
Language Research: Selected Papers from TISLR 2000 (pp. 81–94). Hamburg: Signum.
Tomasello, M. and Farrar, M.J. (1986) Joint attention and early language. Child Development
57, 1454–1463.
Volker, M.A., Lopata, C., Smith, D.A. and Thomeer, M.L. (2009) Facial encoding of chil-
dren with high-functioning autism spectrum disorders. Focus on Autism and Other
Developmental Disabilities 24, 195–204.
von Tetzchner, S. (1984) First signs acquired by a Norwegian deaf child with hearing
parents. Sign Language Studies 44, 225–257.
Warreyn, P., Roeyers, H., Oelbrandt, T. and De Groote, I. (2005) What are you looking
at? Joint attention and visual perspective taking in young children with autism spec-
trum disorder. Journal of Developmental and Physical Disabilities 17, 55–73.
Webster, C.D., McPherson, H., Sloman, L., Evans, M.A. and Kuchar, E. (1973)
Communicating with an autistic boy by gestures. Journal of Autism and Developmental
Disorders 3, 337–346.
Wetherby, A.M. (1986) Ontogeny of communicative functions in autism. Journal of Autism
and Developmental Disorders 16, 295–316.
White, K.R. (2004) Early hearing detection and intervention programs: Opportunities for
genetic services. American Journal of Medical Genetics 103, 29 –36.
Acquisition of Sign Language by Deaf Children with Autism Spectrum Disorder 121
2639_Ch04.indd 1212639_Ch04.indd 121 05-12-2013 18:40:2805-12-2013 18:40:28

Whiten, A. and Brown, J. (1998) Imitation and the reading of other minds: Perspectives
from the study of autism, normal children and non-human primates. In S. Bråten
(ed.) Intersubjective Communication and Emotion in Early Ontogeny (pp. 260–280).
Cambridge: Cambridge University Press.
Wilbur, R.B. (2000) Phonological and prosodic layering of non-manuals in American Sign
Language. In H. Lane and K. Emmorey (eds) The Signs of Language Revisited: Festschrift
for Ursula Bellugi and Edward Klima (pp. 213–241). Hillsdale, NJ: Lawrence Erlbaum.
Williams, J.H., Whiten, A. and Singh, T. (2004) A systematic review of action imitation
in autistic spectrum disorder. Journal of Autism and Developmental Disorders 34,
285–299.
Yirmiya, N., Kasari, C., Sigman, M. and Mundy, P. (1989) Facial expressions of affect in
autistic, mentally retarded and normal children. Journal of Child Psychology and
Psychiatry 30, 725 –735.
122 Part 1: Developmental Language Disorders in the Signed Modalit y
2639_Ch04.indd 1222639_Ch04.indd 122 05-12-2013 18:40:2805-12-2013 18:40:28