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Current Paediatrics (2005) 15, 200 206

www.elsevier.com/locate/cupe

Controversies in the education of deaf children

Wendy Lynas
School of Education, The University of Manchester, UK

KEYWORDS
Severely and profoundly deaf children; Auditoryoral approach; Sign bilingualism; Total communication

Summary In Britain about one child in 1000 is born with sensorineural deafness. Around half of these children have severe or profound deafness, i.e. hearing losses 470 dbHL. A child with a 70 dbHL or more hearing loss will have no natural auditory access to the conversational spoken language surrounding her and this seriously undermines the process of language acquisition. Intervention is necessary if very deaf children are to acquire language and a means of learning. Controversy surrounds the education of deaf children over the choice of method used to unlock the barrier to language and communication. Currently there are three major protagonists: those who advocate an auditoryoral approach that involves no signing; those who believe in sign-bilingualism, a sign-only approach to rst language acquisition; and those who favour total communication, a combination of speech and signs. This article focuses on children with severe and profound hearing losses for whom language and communication are so problematic and examines critically the three major communication options in order to clarify their respective claims. & 2005 Published by Elsevier Ltd.

Introduction
A diagnosis of severe or profound bilateral deafness, whether at 3 weeks, 3 months, 9 months or later, is a shock to parents and generates questions that reect feelings of anxiety and uncertainty about their childs future. Will she talk? How will we talk with her? Must we learn sign, etc.? Unfortunately there are no easy answers to these questions. Speech and language, the fundamental tools for human communication and learning, are so easily acquired by a child with normal hearing
6 Ravenswood, 1 Spath Road, Manchester, M20 2GA, UK. Tel.: +0161 434 0323. E-mail address: wendy.lynas@ravenswood6.fsnet.co.uk.

such that the typical 5-year-old has at her command a vocabulary of 2000 words or so and, remarkably, full knowledge of the grammar of her mother tongue. A child with mild or moderate hearing losses will be able to cope with speech acquisition with only modest help. But a child with severely defective hearing has limited or no access to the spoken language surrounding her. Intervention is necessary if a child with minimal audition is to acquire language and a means of learning. It is the type of intervention, the choice of method for developing communication, which is the source of so much controversy in the education of deaf children. Parents have to make difcult but potentially fateful decisions on behalf of their deaf child and

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Controversies in the education of deaf children will need to make serious enquiries about communication and education options. They will almost inevitably ask questions of the professionals whom they meet. In the early post-diagnosis stages those professionals will include doctors, nurses, audiologists and health visitors. It is highly desirable that professionals who are not primarily educators are aware of the issues and controversies so that they do not fall into the trap of offering glib advice or supercial reassurances to the families of deaf children. The three major communication optionstotal communication (TC), sign-bilingualism and auditoryoralwill, in turn, be examined in order to reveal the arguments used to support each particular method and to examine its practical implications together with the most recently available educational outcome evidence. 201

The case for using signstotal communication

TC involves the use of both speech and signs. The idea is that visual communication will support but not replace audition and speech. Speech and signs, sight and hearing, it is claimed, work together in a TC approach to enable the deaf child to get the best of all worlds from a communication point of view. The signs used in a TC approach are taken from the sign languages used by some deaf people in a particular country. For example, in the UK, the signs are drawn from British Sign Language (BSL) and in the USA from American Sign Language (ASL). The sign system in a TC approach, however, differs from BSL in signicant ways: BSL has a very different structure from the structure of English. BSL is not a manualvisual form of English and cannot, therefore, be used simultaneously with speech. The signing of TC, however, is a signed form of English and, in theory, a sign can be produced simultaneously with each word that is spoken. TC is a contrived system, therefore, which takes signs from BSL but presents them in English word order. It is easy to see the appeal of TC: visual signs are 100% accessible to the deaf child, whereas speech is heard imperfectly. The TC approach appears to offer a deaf child easy communication and access to verbal symbols through sign, whilst at the same time making use of whatever residual hearing the deaf child has.

Failure of oralism and the trend towards total communication

The advocacy of TC was a response to the seeming failure of oralism to deliver its goals. The oral approach is based on the idea that in order for deaf children to take their place in a hearingspeaking society, they should be taught to speak and they should be educated through the medium of speech. Aspirations for the prospects for deaf children rose in the post-Second World War period with the development of audiometric techniques for measuring hearing and the availability under the NHS of hearing aids free of charge. Despite aspirations, optimism for the oral method, which had prevailed in the UK for a century or more, began to wane. Damning reports from governments in both the USA and UK in the 1960s and 1970s1,2 revealed dispiritingly low educational outcomes for the majority of deaf children. British deaf children in the 1970s, regardless of inherent IQ, were typically leaving school with unintelligible speech, lack of mastery of English language, poor literacy attainments and little in the way of educational qualications. Worthy though the goals of oralism might have appeared to be, the oral approach as practised 30 or more years ago was failing to unlock the barrier to communication and learning caused by a substantial hearing loss from birth. Something had to be done if deaf children were to stand a chance of achieving their linguistic and intellectual potential and many educators came to the view that signs as well as speech should be used.

An evaluation of the TC approachevidence of TC failure

Since there have been many years of experience of TC practice, particularly in the USA where TC predominated during the 1970s and 1980s, it should be possible to judge the effectiveness of this approach. Despite the obvious appeal of TC, research evidence suggests that TC does not live up to its claims.

Several research studies have led to the consistent nding that the use of signs and speech beyond the early stages of communication development undermines the acquisition of verbal language, literacy and intelligible speech.35 The large-scale surveys of the attainments of deaf children and young people in the USA in the late 1980s and 1990s offer a serious indictment of

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202 the use of TC during the school years. The surveys, which involved thousands of deaf children and young people, indicated that TCeducated young people were leaving school with standards of literacy and speech achievements that were no higher than those of deaf young people leaving school in the 1950s and 1960s, i.e. before the introduction of TC.6 The majority of profoundly deaf TC-educated children in the USA not only lacked intelligible speech on leaving school but also, with an average reading age of around 8 years, they lacked even basic literacy. Research work in the late 1970s and 1980s offers reasons why TC fails to achieve its goals: W. Lynas condence in communication and is better able to cope with the more difcult task of receiving and producing speech. Hence the claim that the early use of signs facilitates speech communication.11 Parents and members of the family need to learn some basic signs, but the task is not considered to be beyond the scope of the majority of parents. So, what of the evidence for using basic signs in the early years? There have been several research studies, primarily from the USA, which address the signicance of the use of signs with young deaf infants.1215 These included comparisons between caregivers who used signs/gestures together with speech with caregivers who used only speech; comparisons between children who were offered signs/gestures only at the very early stage of communication development e.g. from birth to 18 months with those who continued to use signs up to the age of 4 or 5 years. The studies also included children who were tted with hearing aids within the rst 6 months of life and/or received cochlear implants during infancy. The ndings of these studies can be summarised:

First, TC is difcult to put into practice. A signed form of English takes about twice as long as the spoken form to articulate. Transcripts of speechand-signs indicate distortions to speech, which is slowed down and over-simplied, also distortions to the signed component where signs are typically omitted. This is especially true of difcult vocabulary and signs conveying grammatical information.79 TC has been shown, therefore to be doing the very opposite of what is claimed, i.e. ensuring total linguistic information. Second, speech and signs cannot be received and understood simultaneously. Very deaf children, if presented with signs and speech together are likely to orientate to the signs rather then the speech since it is beyond the capacity of the human brain to decode spoken language through hearing, and signs through vision, at one and the same time.7 Thus, extensive use of TC tends to turn deaf children into visualisers rather than listeners.

TCa route to speech in the early years?

Not all advocates of TC or speech plus signs are in favour of its use throughout a deaf childs educational and communication development. There is a view that using simple signs and gestures during the early years can be an important means of establishing communication between caregivers and young deaf children.10 Deaf infants, like any other, use their eyes to notice objects and events. It is felt that, in response to the infants visual attention, caregivers can offer helpful gestures, such as pointing to objects, miming actions such as washing the face and offer formal signs for, say, mummy or daddy. By being offered sign and gesture in the early years, it is claimed that the deaf child gains

Where signs were used beyond the age of 24 months, speech perception and speech intelligibility were casualties. The deaf children who used signs up to the age of 48 months or later were less competent at using speech and understanding speech than children who used oral communication without recourse to signs. The oral children were considerably superior to the TC children in negotiating with the hearing world, e.g. with non-signing friends and relatives, in shops, etc. Where signs were dropped from communication before the deaf child reached 24 months there was no difference between TC and pure oral children in relation either to language or speech. It would seem that if young deaf children do not become over-accustomed to visual interaction they prefer communication and linguistic symbols in auditory rather than visual form once they have learned to make use of audition. In other words, they become listeners rather than visualisers. There is no evidence that the very early use of signs improves the later development of speech or language, merely that it does no harm. If parents feel they need to use gesture or sign to facilitate very early communication then this is probably OK. However, parents should certainly heed the warning that a deaf child needs a reasonable chance to utilise the auditory information provided by a hearing aid or cochlear implant to avoid becoming a visual learner.

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Controversies in the education of deaf children Overall, TC, if used beyond the very early stages of communication development, does not lead to effective spoken language and intelligible communication. So, what alternatives are there? A new solution of a sign-only approach emerged during the 1990s which in Britain we call sign-bilingualism. Many who had at one time believed that a combination of speech and signs would provide a solution to the problem of giving language to deaf children changed their views and became ercely critical of both TC and oralism.16 Sign-bilingualists offer vigorous and emphatic argument to support their position, so the bilingual case is considered next. 203 member of a cultural and linguistic minority. Moreover, it is argued that any educational approach that does not reect the necessity of sign language as a rst language constitutes a violation of the human rights of deaf children.19

The requirements of a sign-bilingual approach

The sign-bilingual approach demands that sign language, for example BSL, should begin as soon as the infants deafness has been ascertained and that English should be learned later as a second language. Deaf children, so it is claimed, if given sufcient sign language experience in the early years will acquire language as readily as a hearing child acquires spoken language and hence deaf children can begin their formal education on an equal footing with hearing children. Since more than 90% of children born with profound hearing losses have hearing parents, early sign language acquisition is not unproblematic and hearing parents need considerable support. Deaf signing adults can play a crucial role in enabling parents to learn sign language and in offering helpful interaction in sign with the young deaf child. If parents have selected a sign approach they will, so it is claimed, be naturally well motivated to learn sign language themselves.17 Sign-bilingualists argue that once formal schooling has begun, deaf children, through the medium of sign language, can be offered the full curriculum and have the same opportunity as the hearing child to acquire knowledge and achieve academically. Bilingual education requires a generous supply of trained signing teachers, including deaf teachers.

Sign-bilingualism
The true language of deaf people
Sign-bilingualism found favour in some quarters in the USA and UK and became particularly popular in Scandinavia during the 1980s and 1990s. The sign language used in a sign-bilingual approach is the sign language developed within the minority group of deaf people who form what is often termed the Deaf Community. Some, but by no means all, deaf people join signing deaf clubs for companionship and mutual support. A minority within this group who like to be known as the Deaf Community have formed a political pressure group that claims to speak for all deaf people regardless of social afnity or allegiance. This group of committed signing evangelists offers a perspective on deafness that rejects the idea of deafness as a medical condition that requires correction and invites us to see deafness as a cultural feature that needs to be respected.17 It is argued that in order for deaf children to be assured full human rights and equal opportunities, they should be offered their natural language, sign language, as a rst language. Natural sign languages have been analysed by linguists and judged to be proper languages with the same capacity as any verbal language for the expression of ideas.18 Where speech is the medium of exchange, it is argued that the deaf individual can never be equal. Both TC and the oral approach, it is claimed, dis-able deaf children by unfairly imposing on them hearingspeaking goals, goals that deaf children can never attain. Deaf children who are offered sign language as their rst language can communicate as effectively as anyone else, so bilingualists claim, and are thus free from disability. With sign language, deaf children can develop pride in a distinct Deaf identity as a

Achieving English as well as sign language

With the sign-bilingual approach, the goal of verbal language has to be achieved by teaching the deaf child written English as a second language. Bilingualists acknowledge that making the transition between BSL and written English is not easy to achieve given the structural differences between the two languages. It is suggested, however, that signed English can play a role in translating BSL into English.20 Furthermore, it is believed that children of school age are capable of analysing the structure of their rst language and are thus in a position to understand the structure of a second languagea well-accepted principle in second language teaching. There seem to be differences of opinion, or at least emphasis, amongst sign-bilingualists

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204 concerning the development of speech in deaf children. For some, time spent on developing speech is considered time wasted because the goal of speech is judged to be virtually impossible.21 In Britain, however, the most commonly expressed view is that exposure to live or spoken English used in real life situations is important.20 Most deaf children will move in both the hearingspeaking worlds and the deafsigning worlds. Deaf children, it is argued, like other bilingual children in the world, will appreciate when sign language is required and when to use oral communication. W. Lynas of experience of a bilingual approach in Denmark and Sweden, evidence of literacy achievement is lacking. Knoors,23 reviewing a conference in Sweden on Bilingualism in Deaf Education comments: Alas, there were virtually no data, and far too much rhetoric. So far, then, we cannot say with condence that a sign-bilingual approach will lead to competence in English whether spoken or written. Can we accept that the deaf individual without literacy or speech is truly enabled? A bilingually educated deaf child cannot, on becoming an adult, choose to learn to make use of their residual hearing and through audition learn how to speak. If the auditory mechanisms in the brain are not developed during childhood then those neural mechanisms have for ever lost the capacity to develop: the period of neural plasticity is over and the deaf child has missed the boat as far as speech is concerned. We do know, however, that deaf young people and adults who use their residual hearing and communicate through speech can choose to learn sign language and if well motivated have done so, some choosing as adults to communicate primarily through sign.10 The moral and practical issues associated with a sign-bilingual approach seem as great, if not greater, than those associated with the TC and oral-only approach in the past. So, is the choice for parents simply between the ghettoisation of born deaf individuals into non-literate linguistic minority groups or a difcult and marginal existence in a hearingspeaking world? Thankfully not. Those who currently advocate an oral approach have a considerably more positive prognosis for the present and future generations of born deaf individuals and the current auditoryoral case will now be examined.

An evaluation of the sign-bilingual approach

Sign-bilingualism has a strong ideological underpinning and few would quarrel with the principle of respect for cultural and linguistic diversity. However, to acknowledge the validity of sign language as a means of expressing ideas and a means of communication amongst deaf people does not inexorably lead to support for a sign-bilingual approach in the education of all deaf children.

Are the goals of sign-bilingualism achievable? Are they desirable?

Given that the majority of deaf children are born into a home environment where communication is through speaking, there is a serious problem in offering the young deaf child sufcient sign language input in the crucial early years of language acquisition. No matter how enthusiastic parents are about learning to sign, the task for hearing people in learning sign language is at least as difcult as learning Russian and therefore not lightly accomplished. This same difculty, of course, applies to the deaf childs school teachers and interpreters. The promise of age-appropriate language in sign on the child reaching school age is an appealing feature of the sign-bilingual approach. The question is, can this promise be fullled? Some research undertaken in Britain involving four deaf signing mothers with their young, very early diagnosed children indicated that all of the deaf children were, for their age, linguistically considerably behind what is average in spoken language development for children with normal hearing.22 The achievement of literacy is an established goal of sign-bilingualism. Yet despite over a decade of experience of the use of a sign-bilingual approach in the UK, data on literacy achievements does not exist. Furthermore, with around 20 years

The auditoryoral approach

The case for an auditoryoral approach
The ideological position behind the present-day auditoryoral approach is, as it has been with any oral approach at any time, that verbal communication, particularly spoken communication, is the predominant medium of social exchange. Presentday oralists argue that it is not only desirable but now possible to enable even severely and profoundly deaf children to talk and to acquire verbal language. As a result of new knowledge and everadvancing technologies, deaf children can be enabled to use audition far more effectively than

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Controversies in the education of deaf children ever before and hence acquire the spoken language surrounding them. Oral failure and the poor educational attainments previously reported are, it is argued, a thing of the past. 205 words, very early diagnosed deaf children given appropriate amplication can make progress with speech and language in the early years similar to that made by children with normal hearing. The growth in availability of cochlear implantation for young deaf children and the consistent trend towards a reduction in age of implantation. Implantation, a surgical procedure whereby a hearing aid is inserted beneath the skull, bypassing and augmenting the malfunctioning cochlear, is now widely available to profoundly deaf children in the UK at the age of 2 years or less.26 Luterman, writing in the USA, claims cochlear implants y are producing a new kind of child y the hearing deaf child10 Furthermore, deaf children with additional disabilities, who until recently have been excluded from the process of implantation are now being considered for cochlear implantation and this should greatly improve the educational and communication prospects for these children.

Advances in knowledge
Knowledge in the areas of child language acquisition, acoustic phonetics, learning behaviours and audiological technology has been advancing steadily from the days of reported oral failure. There have been enormous technological breakthroughs and oralists today argue that technology, if used effectively, can minimise the negative consequences of deafness.

Recent technological advances

The major breakthroughs that give the present-day oralist so much condence are as follows:

Digital, programmable, smart hearing aids that give a clear speech signal, reduce background noise and are customised to suit the needs of an individual hearing loss.24 The prospect in the very near future, thanks to the present governments commitment to modernisation of audiology, of universal newborn screening for hearing loss. This means that sensorineural hearing loss can be detected at birth and hearing aids tted within the rst month after detection. The importance of amplifying the hearing of severely and profoundly deaf children during the rst year of life cannot be underestimated: the rst months of life have been shown to be crucial to the development of the auditory processing mechanisms of the brain.25 If the deaf childs auditory mechanisms can be activated during this early period, when hearing aid rejection is unlikely, then the foundations for speech discrimination are laid in a similar way to those of hearing children. If deaf children can be enabled to hear from an early age and are offered sensitive spoken language input then they should be able to acquire spoken language during the languagesensitive rst 5 years. Indeed, research from the USA conrms that this is so. An extremely signicant study undertaken in Colorado of the speech perception and spoken language production of deaf children diagnosed and tted with hearing aids before 6 months offers the remarkable but welcome nding that age-appropriate spoken language reception and production can be expected for most deaf children.14 In other

Crucial to current auditoryoral thinking is that hearing aids and implants are working to maximum efciency. However, these devices are complex and ddly and capable of underfunctioning and developing faults. In Britain the standards of audiological management required of professionals continue to rise. It is perhaps more imperative than ever that professionals in the health services work closely with parents and professionals in education to enable the potential benets of current technology to be realised. The pure auditoryoral approach does not offer the born deaf individual a problem-free life: a deaf individual, however successful in acquiring verbal language, intelligible speech and literacy remains deaf. It takes strength and a high degree of selfcondence for the deaf individual to know and accept the limitations of a substantial hearing loss and rise above them, especially when that individual enters the unprotected world of adulthood.27 But oralists would argue that it is the best option on balance and the one that offers the deaf individual the greater opportunities and choice in life. There is more to life than being deaf, it is argued, and the use of an auditoryoral approach allows the deaf individual participation in the wider society and all the very many cultural and interest groups that exist within a diverse society such as Britain. Furthermore, there are plenty of opportunities for orally educated deaf individuals to become part of the Deaf World if they want to do so.

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206 W. Lynas
12. Dowell R, Blarney P, Clark G. Potential and limitations of cochlear implants in children. Ann Otol, Rhinol Laryngol 1996;108(Suppl. 177):11923. 13. Robbins AM. A sign of the times: cochlear implants and total communication. Loud Clear 2002;4:14. 14. Yoshinaga-Itano C. Early identication: an opportunity and challenge for audiology. Sem Hearing 1999;20:31730. 15. Zimmerman-Phillips S, Osberger M, Robbins AM, KishonRabin L. Measuring auditory progress in infants and toddlers. Presented at the symposium for cochlear implants in children, Los Angeles; 2001. 16. Hansen B. Trends in the progress towards bilingual education for deaf children in Denmark. Copenhagen: Centre of Total Communication; 1990. 17. Bouvet D. The path to language: bilingual education for deaf children. Clevedon: Multilingual Matters; 1990. 18. Stokoe W. Sign language structure. Silver Spring, MD: Linstock Press; 1960. 19. BDA, British Deaf Association. The right to be equal. British Deaf Association education policy statement. London: BDA; 1996. 20. Pickersgill M. Towards a model of bilingual education for deaf children. Deafness Edu 1997;21:109. 21. Johnson RE, Liddell SK, Erting CJ. Unlocking the curriculum: principles for achieving access in deaf education. Washington DC: Gallaudet University; 1989. 22. Harris M, Clibbens J, Chasin J, Tibbitts R. The social context of early sign language development. First Lang 1989;9:8197. 23. Knoors H. Book review on bilingualism in deaf education. Deafness Edu 1997;21:534. 24. Ross M. A retrospective look at the future of aural rehabilitation. J Acad Rehabilitative Audiol 1997;30:1126. 25. Jusczyk PW. The discovery of spoken language. Massachussets: MIT Press; 1997. 26. Ramsden R, Tyszkiewicz E, Henderson L, et al. The Manchester Childrens Cochlear Programme 19912002: changing criteria. Presented at 7th international cochlear implant conference, Manchester; 2002. 27. Ross M. Implications of audiologic success. J Am Acad Audiol 1992;3:14.

How to choose?
Parents have the responsibility for choosing a communication approach for their deaf child and they cannot choose all three options since the different approaches are so incompatible. The most important factor, perhaps, is which of the alternative options available to the young child will be least constraining, which will leave most options open to the deaf child on becoming an adult. It is this consideration that should be uppermost in the minds of those making the choice on behalf of the deaf infant.

References
1. Babbidge H. Education of the deaf. A report to the Secretary of Health, Education, and Welfare by his Advisory Committee on The Education of the Deaf. Ref. No. 0-765119. Washington DC: Government Printing Ofce; 1965. 2. DES (Department for Education and Science). The education of deaf children: the possible place of nger spelling and signing. London: HMSO; 1968. 3. Bornstein H, Saulnier K. Signed English: a brief follow-up to the rst evaluation. Am Ann Deaf 1981;126:6972. 4. Geers A, Moog J, Schick B. Acquisition of spoken and signed English by profoundly deaf children. J Speech Hearing Disorders 1981;49:37888. 5. Markides A. Speech intelligibility: auditoryoral approach versus total communication. J Br Assoc Teachers Deaf 1988;12:13641. 6. Schildroth A, Hotto S. Annual survey of hearing-impaired children and youth: 198990 school year. Am Ann Deaf 1991;138:4654. 7. Baker C. How does sim-com t into a bilingual approach to education? In: Caccamise F, Hicks D, editors. American sign language in a bilingual context. Proceedings of the second national symposium on sign language research and teaching. Silver Spring, MD: National Association of the Deaf; 1978. 8. Newton L. Linguistic environment of the deaf child: a focus on teachers use of non-literal language. J Speech Hearing Res 1985;28:33664. 9. Wood D, Wood H. Signed English in the classroom. IV: aspects of childrens speech and sign. First Lang 1992;12:12545. 10. Luterman D, Kurtzer-White E, Seewald RC. The young deaf child. Baltimore: York Press; 1999. 11. Denton D. The philosophy of total communication. Supplement to British Deaf News. Carlisle: British Deaf Association; 1976.

Further Information
1. British Deaf Association (BDA), 13 Worship St., London, EC2A 2AB, UK. 2. Deaf Education Through Listening and Talking (DELTA), P.O. Box 20, Haverhill, Suffolk, CB9 7BD, UK. 3. The Ewing Foundation, 40, Bernard St., London, WC1 N1LG, UK. 4. The National Deaf Childrens Society (NDCS), 15, Dufferin St., London, EC1 8PD, UK. 5. The Royal National Institute for the Deaf (RNID), 1923 Featherstone St., London, EC1Y 8SL, UK.