speech and language development in a parent-infant ...

REPRINTED FROM

ANNALSO F OTOLOGY, RHINOLOGY& LARYNCOLOCY, SEPTEMBER-OCTOBER 1982 Supplement 97, Vol. 91, No. 5 COPYRIGHT 1982, ANNALS PUBLISHING COMPANY

SPEECH AND LANGUAGE DEVELOPMENT IN A PARENT-INFANT TOTAL COMMUNICATION PROGRAM

In the program described, the use of total communication (TC) did not impede speech development in preschool deaf children. Evidence indicates that sign language facilitated the young hearing-impaired child's acquisition of communicative oral speech. Exposure to sign language combined with speech enhanced the meaningfulness of residual hearing and lipreading. Milestones in sign language acquisition paralleled the milestones of spoken language. Young hearing-impaired T C children appeared to learn and express more language at an earlier age than is typical of orally trained hearing-impaired children. This implies that their cognition may not be as severely inhibited because their language acquisition is less severely delayed. This should have favorable consequences for later educational and social development. The families in the T C program were able to normalize their child-rearing activities and relationships.

INTRODUCTION -

-

-

-

A long-term controversy exists between educators advocating a strictly oral and those a total communication (TC) approach to the habilitation of deaf children. A T C program mandates early exposure to manual signs and finger-spelling, always combined with speech and with speechreading training. Advocates of TC point to research findings that indicate the failure of oral educational environments to foster adequate language development among most deaf children and These re~ o r t conclude s that a deaf child who cannot hear or understand connected speech has minimal opportunity to learn language if hislher exposure is limited to oral communication. When manual signs are incorporated into the habilitation approach, more normal language acquisition can occur during the critical early Language, once learned, can then be expressed verbally as speech skills d e v e l ~ p . ~ One need not stress the importance of language for the optimum social, psychological, and educational development of the hearing-impaired ~ h i l d . ~ . ~ - " Advocates of oralism contend that the ability of young deaf children to develop speech is inhibited if they are permitted to communicate in sign language.18 The null hypothesis of our investigation is that the use of sign language in the early habilitation of the significantly hearing-impaired child will inhibit the development of speech. This null hypothesis was examined in the total population of deaf infants, ages 14 to 42 months, enrolled in an early intervention parent-infant program which used TC. This longitudinal study documents the acquisition of speech and language in

these infants. The data were collected bv means of diaries maintained at least weekly on each of the children. A description of the audiometric and medical information on each of the children is provided . METHOD Population. The subjects of this study were all of the hearingimpaired children enrolled in a regional T C parent-infant program from September 1977 to September 1980. The children were entered in the program on the basis of age, geographic location, and handicap. Selection of the program by the parents was not based on its educational method as the parents were not aware, at intake, of the characteristics of TC. Subjects. The 11 subjects ranged in age from 14 to 30 months at entry into the T C program. They left the program at ages31 to42 months (Table 1). There were no uniform intake or exit dates for the subjects, and the total number of months spent in the program varied from 6 to 21 months. None of the subjects had known intellectual deficits. One, subject 4, was multiply handicapped, with a cleft palate and a tracheotomy because of subglottic stenosis that impaired his ability to produce speech (Table 2). Subject 9 had Goldenhar's syndrome with velopharyngeal insufficiency which decreased the intelligibility of her speech. Subject 1 had a progressive neurological illness with ataxia, myoclonus, and retinitis pigrnentosa. All children had hearing parents who agreed to be trained in TC. Six of the children had normal-hearing siblings who were also involved in sign language training. The families' social background was predominantly middle income (Table 3). The children were all thought to have severe to profound sensorineural hearing losses on the basis of brainstem auditory evoked potentials andlor behavioral audiometry when they entered the program. Subject 11 was found to have a severe loss with a puretone average of 83 dB in the left ear and 75 dB in the right ear. The audiometric data on 7 of the 11 children in which audiograms are available are given in Table 4. Subjects 3,6, and 7 had soundfield responses of greater than 90 dB. Subject 1 had soundfield responses at 75-80 dB. Information was available concerning responsiveness to hearing aids in all 11 children (Table 5).

From the Departments of Otolaryngology and Neurology, and the Rose F. Kennedy Center for Research in Mental Retardation and Human Development of The Albert Einstein College of Medicine, and Montefiore Hospital and Medical Center, Bronx, New York. Presented in part at the meeting of the American Otological Society, Inc., Palm Beach, Florida, May 2-3, 1982. REPRINTS - Robert J. Ruben, MD, Department of Otolaryngology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461. 62

63

PARENT-INFANT TOTAL COMMUNICATION PROGRAM TABLE 1. ACE AT DIAGNOSIS AND TIME IN PROGRAM (MONTHS)

Subject No. 1 2 3 4 5 6 7 8 9 10 11 Average

Age at Intake 23 30 16 28 16 20 14 20 20 18 22 20.6

Age at Exit 41 36 37 41 37 35 34 37 33 31 42 36.7

Time in Program 18 6 21 13 21 15 20 17 13 13 20 16.1

i%d 18 30 19 27 19 20 13 22 24 14 22 20.7

Teaching Method. The TC method integrated speech, sign language, finger-spelling, auralloral training, and amplification. Total communication was used to stimulate the language and cognitive development of the infants and to allow communication between infant and parents. Speech and auditory training were coordinated into the normal day-to-day living activities appropriate for each infant's developmental level. Supplementary formal speech and auditory training outside of the program was recommended as soon as the infant appeared to be able to respond to such training; it was instituted in subjects 4 , 8 , 1 0 and 11 (Table 6). Family Instruction Sessions. Each family met weekly for twohour sessions with the parent-infant teacher in the infant room of the local public school in which the program was located. Fathers participated as often as their work schedules permitted. All of the fathers were able to attend sporadically throughout the year and received training in TC. Siblings and other family members were encouraged to attend these sessions. Occasional home visits were made on an "as needed" basis. This enabled the teacher to monitor compliance with the program in the home environment. Two of the 11 infants (subjects4 and 5) received almost all of their instruction in the home setting. These family instruction sessions were structured to give the family members skills for the habilitation of their hearingimpaired child. This was done by demonstration-teaching of the child with the parent observing, and then by having the parent interact with the child under the guidance of the parent-infant teacher. Routine age-appropriate activities such as eating, playing, toilet training, storytelling, bathing, etc, were used as a basis for this instruction, in addition to educational games and tasks. The parents were trained in TC techniques designed to develop the infant's awareness of voice, to foster maximum use of residual hearing and lipreading skills, to develop language input strategies and concept formation, and to promote age-appropriate sensorimotor and cognitive skills. In addition, the parents were made aware of the implications of their child's hearing impairment in terms of hisiher emotional, social, and educational de~elopment.'~ At the end of each session, the teacher gave specific assignments for home reinforcement to be carried out during the next week. The family sessions helped the family group cope with the initially overwhelming problem of having a hearing-impaired child.

Weekly parent education sessions supplemented the weekly instructional sessions.

Data Collection. The data for this study were derived from weekly diary entries for each child collected in a systematic manner. The information came from three sets of observations and was entered after each of the family sessions: 1) each family kept a diary of the day-to-day development of its child; 2) the parentinfant teacher kept a diary of the progress of each child and family while in the instructional environment; and 3) information obtained at the weekly pa:ent instructional session was recorded by the teacher. Diary information used for this report concerned the expressive and receptive speech and language development of each of the children (Tables 8-11), together with an assessment of the families' communicative competence at the time the child left the program (Tables 12 and 13).

RESULTS

Findings at Intake. The communicative characteristics of the subjects at intake are summarized in Table 7. All of the subjects attempted to communis meansof various combicate with their ~ a r e n t bv nations of voice: gesture,'body language, and facial expression. The children would get attention by tugging at their parents' clothing, arms or legs, or by the use of some form of vocalization, eg, whining or crying. Vocal output, at intake, varied from minimal (subjects 4, 5, 9 and 11) to occasional (subjects 1, 3 and 6), to frequent (subjects 2, 7, 8 and 10). There were significant differences between subjects in the character of this vocal behavior, which. ranged from minimal, nondifferentiated sounds, through more varied and consistent vocal play, to actual and deliberate first speech attempts by subjects 2 and 8. Some families used their own system of basic gesture language. The overall communication competence of each of the families was inadequate and inappropriate. Each experienced a high degree of frustration because of their inability to communicate with their hearing-impaired child. Sign Language Development - Receptive and Expressive. The development of receptive and exTABLE 3. SOCIOECONOMIC STATUS O F FAMILIES Level of education Mother Hi h school cofiege Unknown Level of education Father

8"

Hi school Co lege Unknown Marital status First marriage Second marriage Single parent

TABLE 2. ETIOLOGIES O F DEAFNESS Uncomplicated, idiopathic Meningitis Malformation syndromes Vater syndrome with absent labyrinth and no vestibular function (subject 4) Goldenhar's syndrome (subject 9) Progressive ataxia, myoclonus and retinitis pigmentosa (subject 1)

7 1 2

Occupation Mother Homemaker

11

Occupation Father Blue collar Skilled trades Executiveiprofessional Unknown

1 4 5 1

DEE ETAL

64

TABLE 4. HEARING STATUS OF SUBJECTS Ear Right

Subject 1' 2 3t 4 5 6t 7t 8 9 10 11 1' 2 3t 4 5 6t 7t 8 9 10 11

Left

Frequency (Hz) 2000

Age (months)

250

500

1000

36

85

100

105

51 58

85 85

90

NR

NR NR

52 56 36 52

52 56 36 52

8000

105

NR

NR

NR NR

NR NR

NR NR

85

90

100

105

NR

NR

NR

NR

NR NR

NR NR

60

95 75

105 95

95 75

80 50

80

100

110

110

105

NR NR

NR NR

36 51 58

4000

85 90

NR

90

90

95

105

NR

NR

NR

75

100 85

110 100

NR NR 75

NR - No response. 'Pure tone audiogram not available. Behavioral response in free field at > 90 dB. tPure tone audiogram not available. Behavioral response in free field at 75-80 dB.

pressive sign language is detailed in Tables 8 and 9. There was significant and orderly development of expressive and receptive sign language, closely paralleling the stages of spoken language development of normal-hearing children. Comprehension of a number of basic first signs, eg, eat, drink, bed, etc, was almost immediate. Acquisition of these signs resulted in prompt subsidence of what, in some families, was a destructive feeling of impotence and frustration brought about by the parents' feeling of hopelessness in their inability to communicate with their hearing-impaired child. Within a few months, all subjects were understanding simple directions and could respond to "yeslno," "eitherlor," and "where" questions, eg, "Do you want milk or juice?" and "Where are your shoes?" "Where" was the first wh- question word of the English language learned. "What," "who," TABLE 5. AWARENESS OF SOUND WITH HEARING AID Subject No. 1 2 3 4 5 6 7 8 9 10 11 NR - No response.

Awareness Level (dB) 55 45 90 85 NR 85 80 30 75 40 35

"when," "why" and also "how" were acquired later. There was a minimum lag of 1 to 30 days between the understanding of a first sign and its production. Thereafter, the children all moved rapidly from understanding to the expressive use of signs. All of the 11 infants started using signs in a communicative mode within a month of entering the program (Table lo). Subjects 6, 8 and 9 produced their first sign as a meaningful communication within one week of exposure. The oldest, subject 4, who was 28 months at intake, mastered several signs receptively and expressively during his first day of instruction. The youngest, subject 7, who was 14 months at intake, used his first sign at 15 months of age, only slightly later than the age a normal-hearing child produces a first word. The first communicative signs resembled the first words used by hearing children. These identified people, objects, and events important to the child's life, such as favorite food and toys, highlights of the daily routine, and words to influence parents, peers, and siblings. The earliest signs produced by the TABLE 6. SUPPLEMENTAL INTERVENTION (SI) Subject 4

Age S I Instituted (mo) 39

Months of SI Before Exit from Program

8 10 11

31 29 36

6 2

2

6

Type of Intervention Oral, motion and swallowing therapy Speech therapy Speech therapy Speech therapy

65

PARENT-INFANT TOTAL COMMUNICATION PROGRAM TABLE 7. COMMUNICATIVE CHARACTERISTICS OF SUBJECTS AT ENTRANCE 2

3

4

youngest signers (subject 7,15 months; subject 5, 17 months; and subject 10, 19 months) were infantile approximations of adult signs, just as the first words of hearing infants are approximations of adult speech. After learning their initial signs the subjects displayed a number of behaviors commonly seen in normally hearing children who are first beginning to communicate in recognizable speech. These included visual-attending behavior, experimental finger and hand play, and both imitative echoic type signing and spontaneous jargon signing. These visual and signing behaviors of the hearingimpaired children correspond qualitatively to the auditory and oral behaviors of hearing children. Like hearing children, the hearing-impaired children's first (signed) utterances were single signs that stood for an entire sentence. Depending upon the context in which it was used, a single sign would communicate a number of diverse meanings. The sign for "shoe" could mean "My shoe lace is untied again", "My milk spilled on Daddy's shoe", or "Put on my shoes so I can go outside." The sign "hurt" was a particularly functional sign for these children who had a limited signing vocabulary. Even the youngest signer quickly learned to position the "hurt" sign over the injured area to show which specific area needed parental attention: eg, "I hurt my knee." This communicative behavior parallels the "one-word sentence" holophrastic stage that marks the beginning of expressive language in hearing children.

5

Subjects

6 Communicateswith ++++ ++++ ++++ ++++ ++++ ++++ body langua e, gesture and/or kcial expression Gains attention by ++ ++ ++ ++ ++ ++ using voice or crying Gains attention by +++ +++ ++ ++ +++ +++ tugging Vocalizes when playing + + +++ ++ + + ++ Makes speech attempts + ++ + + + + Frustratedatneedsnot + + + +++ ++++ ++++ +++ +++ being met by parents + - Almost never; + + - Occasionally; + + + - Frequently; + + + + - Almost always. 1

7

8

9

10

11

++++ ++++ ++++ ++++ ++++ +++

+++

++

+++

++

+++

+

+++

+++

+

+++ +

+++ ++

+

+++ +

+ +

+++

++

+ +++

++++ ++++

phrases expressing question and negation. "Who" and "what" questions were first expressed by pointing, accompanied by a questioning facial and body expression. "Where" was almost immediately used as a formal sign when it was introduced into the child's lexicon, Negative statements were observed very early. For example, one child made the sign for medicine and shook his head vehemently in the negative fashion, conveying emphatically that he did not want his medicine. The two-sign phrases used by the subjects expressed the same relationships recorded in the speech of hearing children, eg, ,"More milk" (recurrence); "Daddy shoe" (possessive); "baby cry" ~' constructions were also (agent a ~ t i o n ) . Negative identical to the first negative phrases of hearing children, eg, "no eat," "no bed," etc. Assessment of finger-spelled items included in Table 9 show that 8 of the 11 subjects were able to finger-spell the entire alphabet imitatively or from a wall chart before they were 3 years old. Three of the subjects were beginning to finger-spell simple words or familiar names. They could also produce the hand formation corresponding to four or more printed letters of the alphabet. The comparison of the growth of vocabulary in speech and sign is found in Tables 10 and 11. All of the subjects except subject 8 learned more signs faster than spoken words.

Speech Development and Verbal Behavior. Seven of the 11 children had a hearing aid at the time of intake. The remaining four acquired them within three months of entering the program (Table 1).

The sequential development of signs paralleled that of speech (Tables 8-10). Both the signers and hearing children progressed from one-word sentences to the "telegraphic speech" stage of two- and Only subject 9 progressed three-word ~entences.~O-~~ beyond this stage and was signing age-appropriate standard English phrases and sentences when he finished the program at 37 months.

At intake seven of the subjects used their voice minimally, while the other four produced frequent vocalizations (Table 7). Most of the vocalizations were in the category of nondifferentiated sounds. Subject 2 and subject 8, who was unaided, produced several differentiated sounds in apparent speech attempts before entering the program.

"Shortcut" questions and negative forms often preceded the appearance of more standard two-sign

All of the children (Tables 12 and 13) learned to understand and respond to the signed directions

66

DEE ETAL TABLE 8. DEVELOPMENT O F SIGNING SKILLS - RECEPTIVE

Skill 1 2 Understands and responds to yeslno questions 23 31 Understands 10 everyday basic signs 24 31 Understands (and follows) simple requests 24 32 Understands "where?" 25 31 Can "give me," "show me" on request 25 32 Understands "help me," "do you need help?" 30 34 Will point to familiar objects when signed 35 32 Will point to 3-5 pictures in a book when signed 27 32 Understands "same" Understands "open," "close" Understands "in," "out" Understands "on," "off' Understands "put it back" Understands "clean-up time" Understands "under" Understands "over" Understands several animal signs Recognizes name signs of family members Recognizes own name sign Understands "your turn - my turn" Understands "finished1 - nextl" Understands "where does this belong?" Understands "not now . . . later" Understands toilet sign for bathroom needs Understands at least two color signs Appears to understand "who" Understands and responds to "what's this?" "what's that?" Appears to understand "what happened?" Understands and follows series of two related commands Appears to understand simple signed stories Can "read and understand" finger-spelling of simple words or familiar names 40 (53) Understands "which one do you want?" 36 36 Understands "why" questions (48) ( )Information obtained after the subject left the program. 'Average = 34.3 without subjects 3 & 5. "Average = 33.3 without subjects 3 & 5. "'Average = 31.4 without subject 10.

3 17 17 18 21 28 28 28

Subject by Age in Months 5 6 7 8 29 17 25 18 20 29 17 25 18 20 30 18 25 22 20 30 20 26 22 20 38 24 28 24 21 38 24 28 24 23 30 24 28 34 21

9 21 22 22 21 22 24 24

10 20 21 23 24 26 26 23

11 23 24 24 25 29 34 28

Average 22.2 22.5 23.5 24.1 27.0 28.5 27.9

28

30

26

24

28

27.4

41 (48) (57)

(53) 34

34 28 30 31 37 36.8 without subjects 3 & 5. 33.8 without subjects 9 & 11. 32.7 without subjects 3, 5, 7.

31

34.2 49.5

given for speech training and speech stimulation. The child (subject 4) with the tracheotomy and cleft palate mouthed visible lip, movements and would produce an occasional "ah" vowel and an "m" consonant when his airway permitted vocalization. The other ten children imitated an increasing number of speech sounds and single words. They learned how to combine sounds with signs in response to the frequently signed direction, "Use your voice - I want to hear you when you sign to me." There was considerable variation in the difficulty each child experienced in producing audible words. Four of the 11children did so with less effort than the other 7.

4

24

28

(56) TAverage TtAverage f TtAverage

= =

34

20

Subjects 4, 8, 10, and 11, whose development suggested they would be able to utilize this additional help, were given speech and auditory training by speech and hearing clinicians outside of the program (Table 6). These four children responded favorably to the additional intervention when they worked with signing speech clinicians. Ten of the 11 subjects used spontaneous verbalizations on occasion when signing, and 3 could verbalize two- or three-word utterances, in combination with sign, when they left the program (Tables 12 and 13). The only child who could not do this was subject 4, with the tracheotomy and cleft

PARENT-INFANT T O T A L COMMUNICATION PROGRAM

67

TABLE 9. DEVELOPMENT OF SIGNING SKILLS - EXPRESSIVE

Skill

1

2

3

First sign used 24 Used 10-20 signs 27 Signs "where?" 25 Signs "no" 25 Signs "yes" 25 25 Signs "up," "down" Signs "in," "out" 29 Signs "open," "close" 25 Signs "on," "off' 29 Can sign toilet needs 25 29 Uses 50 + signs Uses "mine" (possession) 29 Uses "same" appropriately 31 Uses name signs of family members 29 29 Uses 75 + signs 28 First 2 sign phrases "I want" phrases 36 Names at least two colors 35 "Reads" books by signing picture contents 31 Signs to self and toys in make-believe play activities 29 32 Uses 100 + signs First 3 sign phrases 28 (48) Uses "what?," "what's this" Uses "who," "who's that?" (48) Begins to communicate about past experiences 41 Begins to,Pescribe feelings, eg, "scared," "tired, "angry" 36 Uses 200-300 signs 36 300+ signs Uses signs continuously to express wants and needs 29 Uses signs conversationally, to share experiences with others 36 Can sign 6 letters of manual alphabet 36 Can sign entire manual alphabet from wall chart 38 Can sign 4 or more letters of alphabet in correct correspondence with printed symbol (48) 40 Can finger-spell simple words or names ( )Information obtained after the subject left program. 'Average = 29.0 without subject 10. "Average = 31.8 without subject 5. "'Average = 33.0 without subject 7. ""Average = 35.4 without subject 7.

palate. Two of the children (subjects 2 and 8) made occasional speech attempts without sign. Follow-up studies on these children at 5 years of age show that they use speech alone when attempting to communicate with individuals who do not sign. All except subject 8 acquired new sign words more quickly than new speech words. Except for subject 8, all children had larger active signing vocabularies than speech vocabularies at exit (Tables 10 and 11). The intelligibility of the children's speech generallv was Door. The most intelligible words were the simplest, such as "mama," "bye-bye," etc. Signs were necessary with almost all speech efforts to clarify the meaning of the speech utterance. The

-

Subjects by Age in Months 4 5 6 7 8

41 41

(40) (50) TAverage ttAverage TttAverage t t t tAverage

= = = =

9

10

11

Average

24 29 (36) 30.8 without subjects 7, 10. 31.5 without subject 1. 35 without subjects 1, 5. 38 without subjects 5, 8.

variability of children's acquisition of speech is noted in Table 11. All of the subjects showed an increase in oral behavior and speech attempts as their signing proficiency increased. Follow-up information was obtained for 9 of the 11 children. Of those nine, eight were using speech, while speech development was slow in one. Eight of the nine were attending preschool for hearingimpaired children, and one attended a regular kindergarten with a resource program. DISCUSSION

This study provides information about the speech development, auditory training, language acquisition, and communication competence of young deaf

68

DEE E T A L

TABLE 10. DEVELOPMENT OF EXPRESSIVE SIGN LANGUAGE

Subject

1 2 3 4 5 6 7 8 9 10 11 Average A

Fir.st Sign A No.

24 31 17 28 17 20 15 20 20 19 23

(1) (1) (1) (0) (1) (0) (1) (0) (0) (1) (1) (0.6)

10-20 Signs A No.

27 32 24 29 19 24 23 21 22 22 25

(4) (2) ((8

(1) (3) (4) (9) (1) (2) (4) (3) (3.7)

50 + Signs A No.

28 36 29 34 21 28 27 22 26 26 29

(5) (6) (13) (6) (5) (8) (13) (2) (6) (8) (7) (7.2)

75 + Signs A No.

100 + Signs 200 + Signs 300 + Signs Signs A No. A No. A No. AtExit

29

(6)

30

(7)

36

30 35 24 30 32 22 28 29 30

(14) (7) (8) (10) (18) (2) (8) (11) (8) (9.2)

32 36 28 32 34 23 28 31 33

(16) (8) (12) (12) (20) (3) (8) (13) (11) (11)

37 40 36 35

Age Age Began Left Program Program (Months)(Months)

27 33 42

- Age in months; No. - Number of months in program.

children in a total communication environment. It also highlights psychological, social, and educational consequences of this approach.

Acquisition of Speech with Sign. The data do not support the null hypothesis that the use of sign language inhibits the development of speech. The data clearly show that all of the children with an intact speech tract acquired speech vocabularies and made oral attempts while signing. The findings in this study are consistent with those of Meadow and S ~ h l e s i n g e r , ~who , ' ~ recorded similar findings in four children. The children in the present study all increased their verbal behavior as their signing skills increased. More speech attempts were made in conjunction with signs than without signs, suggesting that sign language makes speech production more relevant. Intelligibility. The lack of the intelligibility of the speech of significantly hearing-impaired children and adults, especially the congenitally deaf, is well documented. '.'8.23.24Conrad' reports that in England only 10% of profoundly deaf 15- to 16year-old teenagers who had received at least ten years of strictly oral training spoke well enough to be understood by strangers. This communication barrier did not exist for the children in this study since all their speech efforts, no matter how imperfect or distorted, acquired immediate meaning because they were associated with the corresponding sign. Intelligibility, the ability to associate a verbalization with its sign so as to communicate unambiguously, begins with the earliest attempts at language. The first word of the oral deaf toddler, "buh," will have a variety of meanings which are important to the child. Thus "buh" could mean, in different contexts, "bottle," "ball," "balloon," "boat," "bubble," etc. The parent will have difficulty determining which of these words the child is conveying when he says "buh." The TC family es-

capes the frustration of degraded intelligibility and its barrier to understanding since the child will also produce a sign which clarifies the meaning of the speech word. There will be no ambiguity about the meaning of "buh" with the sign for "bath" as opposed to the combination of "buh" with the sign for "bottle."

Comparison of Rate, Complexity and Extent of Acquisition of Verbal and Sign Language. All of the children, except subject 8, acquired new signs faster and with greater ease than new verbal words. This was an expected finding in view of the known difficulties hearing-impaired children experience in acquiring speech.25The complexity and extent of the children's active sign vocabulary was greater than that of their oral vocabulary, with the one exception. Ten of the 11 children would be considered substantially delayed in language development if only their oral language was measured. However, when their total language skills, including sign, are measured, they are all found to approach age level for expressive and receptive language. This information supports the concept that language is not dependent upon the mode of reception or expression. Furthermore, there may be a "critical" period for the establishment of l a n g ~ a g e .The ~ ~ children -~~ in this study acquired language during this critical period and should be able to build upon this language base as they grow. Children who are deprived of a language base during the critical period may be significantly impaired in their ability to acquire normal linguistic skills and thus become functionally retarded. The manual signs provided the children with an adequate channel for communication without having to wait for speech to have developed to the point of giving them a functional verbal vocabulary. These early manual signs laid the foundation of language and enabled the children to acquire more extensive, complex, and varied lexicons than that of deaf oral-

69

PARENT-INFANT TOTAL COMMUNICATION PROGRAM TABLE 11. DEVELOPMENT OF EXPRESSIVE SPEECH

Subject

First Word A No.

1-5 Words A No.

5-10 Words A No.

10-20 Words A No.

20-25 Words A No.

No. o WorA At Exit

Age Began Age Left Program Program (Months) (Months)

A - Age in months; No. - Number of months in program. 'Had first words before entering program. THad cleft palate and tracheotomy; could not produce speech.

ly trained children of a comparable age.25,29.30 Subject 8 developed differently from the rest of the group: he had the more extensive sign and speech vocabulary of all of the children and his speech and sign developed at the same rate. Yet his speech was often unintelligible, requiring him to use sign to convey his meaning clearly. He also used his knowledge of sign to understand and respond to his communicative environment. This child's hearing loss was no less than that of many of the other children in the group. The biological or psychological reasons for his rapid linguistic development is not known, except that his parents, both hearing, became very good signers and provided an enriched linguistic environment. This boy has progressed to the point where he is now partially mainstreamed in an oral classroom with a sign language interpreter.

Distinction Between Speech and Language Development. A clear distinction must be made between speech and language acquisition when one considers the communication handicap of deafness. When a deaf child is taught how to speak or lipread a particular word, this does not guarantee that the child knows language or the meaning of the word. Language ability is the child's ability to understand and communicate ideas, needs, and feelings. Children learn language by using it freely, first with parents, then with peers, and with other adults. A deaf child who cannot hear or understand connected speech has a minimal opportunity to learn language if hislher exposure to language is limited to oral communication. A young TC child can develop and expand both language competence and communication skills through constant and meaningful usage of the language of signs, thereby reaching closer to normal levels of linguistic and communicative functioning.

Language Acquisition and Communication Com-

petence: Comparison of Young TC and Young Oral Child. There is no substantive data base concerning the language acquisition and communication competence of young deaf children who have been exposed to an exclusively oral program. The only available information is its outcome in older schoolchildren. These data uniformly demonstrate that almost all orally trained children have substantial language and communication retardation in receptive and expressive abilities for both speech and reading." One area in which the TC children in our study had a clear advantage over orally trained children was in their knowledge and use of question and anTABLE 12. COMMUNICATION COMPETENCE OF SUBJECTS AT EXIT Two-word sentence Three-word sentence Mostly holophrastic Mostly phrases and sentences Imitates oral speech with signs spontaneously Initiates oral speech on commands Initiates oral speech spontaneously without sign Communicative competence in family sufficient for normal activities Conversational language Conversational language age - appropriate for hearing child Concept of "where" receptive Spontaneous and appropriate use of "where" Can finger-spell manual alphabet from wall chart Can finger-s ell more than 4 letters in correct corresponience to 2 printed symbols Be 'nning to finger-spell single words and gmiliar names Using "my," "mine" appropriately Has concept of "sameldifferent" and uses "same" sign appropriately Answers "what's this?", "who's this?" question

Yes

No

11

0 4

7 9 2 7

2 9 4

9 6

5

11

0

7

4

1 11 10 8

10 0 1 3

3

8

4 10

7 1

11

0

9

2

2

.

DEE E T A L

70

TABLE 13. COMMUNICATION CHARACTERISTICS OF SUBJECTSAT EXIT

Never Verbal response or verbalization for speech tasks at imitation or on command Single words elicited Two-word utterance elicited Three or more words andlor phrases elicited Spontaneous vocalization while signing Initiates deliberate speech attempts while signing single words Initiates while signing two-word utterances Initiates while signing three words or more andlor phrases Deliberate speech attempts without sign Intelligible without sign Intelligible with sign Signs without vocalizing Vocalizes while signing Signs with meaningful speech or speech attempts Uses spontaneous speech or speech attempts without signing Frustration at needs not being met by parents

swer forms. Quigley et a13' showed that this was an area of serious linguistic deficit in older deaf children in that many of them were neither able to ask nor to answer questions appropriately. All of the children in this study were able to process and respond to a variety of question and answer forms. This suggests that TC may make a significant difference in early language and communication competence. The TC children in this study were able to commupicate at an age-appropriate level in the sense that their parents could fulfill their normal child-rearing roles. There was social communication and communication concerning environmental events and the daily routine of family life. The children were able to make themselves understood and to understand language close to their age level. This is not the case of older orally trained children or those exposed to T C only by school age. One would expect that children exposed to TC from infancy or toddler age will continue to develop language-at a more nearly normal rate and that the final outcome will be a person with more functionally appropriate communication skills to interact in society. le The enjoyment and relative ease with children in this study acquired receptive and expressive language stands in stark contrast to the frustrations and difficulties of young children attempting to communicate in the oral mode.32Total communication families used a wide range of channels for satisfactory interpersonal communications which, in our experience, few strictly oral families achieve. Effective communication with teachers and peers was also facilitated. In the oral' deaf child, communication is limited to the child's ability to understand and produce intelligible speech. His communicative capacity is

0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0

Almost Never

1 1

7 9 1 1 8 9 8 8 0 5 2 1 8 1

Occasionally

Frequently

Almost Always

2 5 2 0

4 2

4 3

0

2

1 2 2 1

1 5

3 6 1

1 3 2 0

2 2 6 3 10

2

2 2

1 1 0 0 11 1 5 2

0 0

0 0

0 0 0 0 3

much more restricted than that of the TC child whose skills approach those of the hearing child both quantitatively and qualitatively. The TC child's ability to use both speech and sign greatly enhances hislher intelligibility. Previous dataz5 show that the orally trained deaf child has little or no verbal capacity at age 5 or 6. The children in this study, at 3 years of age, were communicating with greater ease, flexibility, and diversity than many older oral deaf children. Language development appears to depend on the acquisition of certain basic communicative skills in early life. The TC children's acquisition of this basic substrate affords them the opportunity for language growth. The oral children's markedly retarded language may be attributed to the lack of this basic language substrate. Quigley et a13' predicted that the use of TC during the early stages of language development would foster better language skills in deaf children. Our observations support this prediction. Zmplications of Parent-Infant TC for Speech Deuelopment, Speechreading Skills and Utilization of Residual Hearing. Signs ensured that each newly developed speech sound would be incorporated into a meaningful communicative act. For example, "m" used with the sign for "milk," "mom," etc, was reinforced in a meaningful manner, rather than being taught through meaningless repetition of a speech drill. Sign language enabled the speech therapist, the teacher, and the parent to give clearly understood directions for speech training tasks, speech games, and speech situation activities. It also enabled the instructor to develop more effective speech skills, using signs to tell the child to use hislher voice, make a loud sound, make two short sounds, etc. The child was not dependent on hislher mastery of the meaning of oral words to acquire specific speech skills since the meaning of the word

PARENT-INFANT TOTAL COMMUNICATION PROGRAM

71

TABLE 14. TOTAL COMMUNICATION COMPETENCE OF PARENTS AT EXIT FROM PROGRAM Mothers Fathers Total

Beginner 1

Fair 2

5 6

1 3

Good 6 3 9

Excellent 2

1 3

could be conveyed through its sign. The use of sign also improved the efficacy of lipreading. Signs fostered the use of residual hearing by giving meaning to the auditory component of the spoken communication. Both parent and teacher were more effective in reinforcing the traditional auditory training procedures by bringing environmental sounds to the child's attention, helping himlher to localize them and explaining their source, their significance, and other attributes. Signs were an efficient means of informing the child of the auditory environment; in fact they were the tools with which the child could come to understand hislher world. Effect on Parents. Early intervention programs for deaf infants place special demands on parents. Parents are expected to participate in many aspects of their infant's remediation and to become knowledgeable about deafness and its implication^.'^ They are also expected to support and enhance the optimum development of their child by becoming skilled in home reinforcement of therapies and in training procedures. A TC program commits the parents to learn sign language and to create an effective home environment for total communication. Parents need ongoing counseling and sustained educational services to allow them to become effective in the program. Experience from this study indicates that the sign language program for the parent should emphasize the signs needed for day-to-day living.

There needs to be an appreciation of the parents' overwhelming feeling of loss when they first realize that their child is deaf. Continued involvement of the parents, from the start of habilitation, allows them to begin to function in such a way as to help their child to overcome hislher handicap. Their ability to communicate with their child enables them to fulfill their natural need to parent. When parents are limited to the oral mode of communication there will be much that they cannot convey to their child; this results in deep feelings of frustration, anger, and despair within the family. How can a parent communicate the concepts of good and bad, religious beliefs and cultural values, or even tell a story or make a joke with the extremely limited avenue of oral communication? Signs allow the parents to communicate all of the above and more to the child and ensure a much more normal childparent relationship. Table 14 shows the parents' variable fluency in use of sign. All of the parents did advance to at least the level of an advanced beginner. Mothers were us-

ually more proficient than fathers; this was probably due to mothers' more consistent use of signs. Even in those families in which TC skills were minimal, signs provided a pleasurable mode of communication between child and parent. Most importantly, all of the families established communicative competence. It was our feeling that their level of competence was greater than that of families limited to oral communication alone. Despite the difference in communication competence among families, all had, at the time of exit from the program, adequate and appropriate basic communication skills for their day-to-day needs. CRITIQUE

The original purpose of the diaries used in this report was to provide the parent-infant teacher with ongoing information so that she could assess progress in parent-infant communication and so that she could set new goals andlor make changes in the individual educational plan. All the diaries represent a sample in time of the progress of each child; they document the child's and the parents' progress over time. Quantification of the growth in the vocabulary for the first 100 signs and the first 100 verbal utterances was precise. Once the child had more than 100 items in his vocabulary, counts became less accurate. The parents found it difficult to keep track of new signs. Data on all lexical,items above 100 are only approximations and probably represent minimal estimates. It would have been ideal to have audiovisual documentation of each child's progress. This avenue of data collection should be explored in the future. The number of subjects is small but they do represent the total population of this program. This sample appears to be representative of the total population of congenitally hearing-impaired children in terms of etiology and the extent of their hearing loss. Therefore, the observations made from these children can probably be generalized to other hearing-impaired infants without significant mental retardation or other neurological deficits. Multiply handicapped deaf children may even benefit more from a T C program than "normal" deaf children because of their curtailed ability to process information. CONCLUSIONS

Total communication (the use of manual signs with orallaural language) does not inhibit the development of speech. There is evidence suggesting that it facilitates the development of speech. Total communication provides a channel for early communication between the hearing-impaired child and hislher family. In addition, total communication fosters the development of linguistic skills that begin to approach those of hearing children.

DEE ET AL

72

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