For most infants identified with hearing loss, the primary developmental concern becomes language development and the corresponding domains that rely on timely language acquisition, such as cognition and socioemotional development. These concerns arise because most families do not know a signed language, and hearing technology doesn't offer a cure, creating a communication mismatch at home for many deaf children. Attempts to resolve this mismatch are typically child-centered through the use of technology such as hearing aids and cochlear implants, and often without taking advantage of the visual modality by incorporating the learning of a signed language (best estimates suggest less than 10 percent of deaf children in the United States and two percent worldwide receive early signed language exposure).1,2 Evidence suggests that relying solely on spoken language acquisition via hearing loss technology increases the risk of deaf children experiencing poor language acquisition and the associated developmental consequences.
Medical and education professionals with limited knowledge and understanding of signed languages can negatively influence parent decision-making about what language approaches to proceed with for their deaf child.3,4 This includes professionals who are on the front line of service provision such as audiologists. Despite being well-positioned to advise parents and caretakers on the necessity of access to natural signed languages to promote their healthy development, audiologists can effectively restrict parents’ options through the type of advice and knowledge they choose to share, especially if they are not knowledgeable about nor supportive of the use of signed languages.
MISCONCEPTIONS ABOUT SIGNED LANGUAGES
Signed languages are natural human languages linguistically equal to spoken languages; in the same vein, signed languages carry the same neurocognitive benefits that any spoken language does in childhood. As with spoken languages, signed languages display phonetic, phonemic, syllabic, morphological, syntactic, discourse, and pragmatic levels of organization as expected of natural languages.5 Today, over 200 distinct signed languages are being used in vibrant communities. There is widespread interest in signed languages, and a growing number of people learn and use sign languages around the world.6
Unfortunately, misconceptions still exist about the interaction of spoken and signed languages in the language development of children with hearing loss. One frequent misconception is that early use of natural signed languages interferes with spoken language development.7 This has been repeated by educators, audiologists, and other speech and hearing care professionals for over a century despite having no evidence to support this claim and, in fact, an abundance showing the opposite is true. Consequently, interventions for deaf children often adopt a single approach of spoken language acquisition through the use of auditory technology, such as cochlear implants. Non-signing children with cochlear implants, however, have highly variable and often delayed spoken language outcomes, whereas children exposed to a signed language from birth have good spoken language outcomes.7-9
Early immersive exposure to a natural language is crucial to the neurocognitive and linguistic development of any child. For most deaf children, access to a signed language fulfills this vital need since unhindered access to a spoken language is not possible.10,11 Indeed, many deaf children who receive high-quality spoken language interventions nonetheless do not achieve age-appropriate linguistic fluency.7 This fluency can be supported by access to a signed language.11 Recommending exclusively oral-aural approaches for children with hearing loss puts them at risk of language deprivation.
RISKS & RESTRICTIONS TO ACCESS
A child's first (approximate) five years of life is a critical time for brain development and the establishment of first-language fluency.10 A consistent lack of unhindered access to a natural language during the neurocritical period of language acquisition may lead to a set of symptoms in adulthood known as language deprivation syndrome. Evidence suggests that language deprivation, not hearing loss, is the underlying cause of poor educational and linguistic outcomes among deaf people—traceable to a lack of signed language exposure for deaf children in their early development.10
The effects of language deprivation can be seen in developmental delays, attention-deficit disorder, and socioemotional difficulties.11,12 In contrast to children who have had a timely acquisition of signed language, permanent neurostructural differences (such as less myelination of neurolinguistic pathways) have been found in deaf people with delayed exposure to a signed language.13
Lack of optimal language exposure can lead to delays in cognitive development. This includes delays not only in academic learning and socioemotional development but also in the development of more fundamental social cognition skills such as theory of mind abilities, which allow a child to recognize different mental states and perceptions in others.14 Symptoms of language deprivation syndrome include language dysfluency (lack of fluency in a first language), general knowledge gaps about the world, disruptions in thinking, mood, and/or behavior, and general academic and literacy delays. This condition represents the atypical cognitive and behavioral development that can occur when early developmental language exposure is hindered.12,15
Auditory and spoken language-only approaches that reject early immersive use of signed languages do not promote ideal developmental outcomes in deaf children. While some professionals may suggest a signed language can be learned later in life if spoken-language outcomes are not achieved, the effects of language deprivation cannot be entirely remediated by the later use of a signed language.16 With cochlear implants carrying variable and unpredictable outcomes in non-signing children, hearing loss technology does not prevent or fully remediate ongoing effects of language deprivation.7-10, 17 Parents who do not have the option of receiving bilingual, spoken, and signed language early intervention services may need to make decisions about learning either a signed or spoken language with little certainty about the ultimate outcome if signed language is excluded.18
SUPPORTING CAREGIVERS’ INFORMED DECISIONS
Caregivers should be advised to learn a signed language and enroll their children in signed language-medium early intervention programs. The evidence strongly indicates that first-language development via an accessible signed language is often a precondition for deaf children being able to understand and use spoken and written languages.12 Deaf children with adequate exposure to a signed language can achieve age-appropriate development milestones.7 We emphasize that signing children with cochlear implants demonstrate better speech and language development than non-signing children with implants, and the development can be on par with that of non-deaf children.8,9
Accessible communication with parents and peers supports children's social and emotional development, including self-esteem and the ability to build relationships.19 Non-deaf parents in the United States are three times less likely than deaf parents to use a signed language with their deaf child.20 In many countries, resources exist for parents to learn a signed language and gain improved communication with their children. The importance of early accessible communication with family members and peers can be seen in the dinner table syndrome—the chronic experience of observing spoken conversations between other family members and not understanding what is being said. This is often experienced by deaf children from non-signing families. Lack of accessible communication with peers and family members is a factor that affects mental health issues later in life.11 Experiences of dinner table syndrome were prevalent regardless of whether the children had cochlear implants or hearing aids.21 Caregivers should be encouraged to access resources to promote signed language use at home to foster effective communication and promote deaf children's long-term socioemotional development.
RECOMMENDATIONS FOR EARLY ACCESS
Early and consistent exposure to signed languages is crucial for many deaf children to receive fully accessible language input. This avoids the risk of an artificial ceiling on developmental and educational outcomes where poor outcomes are often misattributed to hearing loss. Deaf children and their families should be able to access early intervention in their national signed languages at schools, agencies, or resource centers. These centers should provide children with language-rich environments where they are able to acquire at least one natural language at an age-appropriate pace, and provide parents with signed language education. Audiologists and hearing health professionals should recommend that children with hearing loss and their families seek out signed language-based early intervention to ensure maximum language input in the critical early years.
Funding: WCH was supported by the University of Rochester CTSA award number 3 UL1 TR002001-03S2 from the National Center for Advancing Translational Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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