Develop mental Psychology Copyright 1998 by the American Pj,yu bo logical Association, Inc.

1998, Vd. 34, No. 5, 840-850 00]2-1649/9S/$3.00

Audition and Visual Attention: The Developmental Trajectory

in Deaf and Hearing Populations
Linda B. Smith and Alexandra L. Quittner Mary Joe Osberger
Indiana University Bloomington Advanced Bionics Corporation

Richard Miyamoto
Indiana University School of Medicine
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This study examined the development of visual attention in 5- to 13-year-olds who differed in their
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access to sound. Hearing children, deaf children with cochlear implants, and deaf children without
implants participated in a task in which they were to respond to some visual signals and not others.
The results of Experiment 1 indicated that the timing of developmental changes in visual selective
attention was similar for all 3 groups, occurring around 8 years. The magnitude of age-related change
differed among groups; hearing children and older deaf children using a cochlear implant reached
higher levels of performance with age than did deaf children without enhanced access to sound. The
results of Experiment 2 suggest that the developmental differences between deaf children with and
without cochlear implants begin prior to 8 years and may be related to their use of environmental
sounds to organize visual attention.

Shortly after birth, newborns look in the direction of sound
(e.g., Mendelson & Haith, 1976; Wertheimer, 1961). With fur-
ther development, this early control of visual attention by sound
quickly becomes more complicated, such that infants look at
visual events whose temporal rhythms match what they hear
(e.g., Kuhl & Meltzoff, 1988; Spelke, 1979; Walker-Andrews,
1988; Walker-Andrews & Lennon, 1991). Other evidence sug-
gests that corresponding sights and sounds lead to deeper visual
processing by infants, children, and adults (Butterworth, 1981;
Morrongiello, 1994; Perrot, Saberi, Brown, & Strybel, 1990;
Roberts, 1994; Roberts & Jacobs. 1991). In brief, from early in
development, sound plays a role in organizing visual attention.
It seems likely that this tight coupling between what the devel-
oping child hears and where he or she looks organizes the child's
behavior and learning (Smith, 1994; Smith & Katz, 1996).
If this is so, if hearing and seeing strongly interact in the
control of visual attention, what happens when one modality is
lost? This article addresses this question by examining how the
loss of hearing influences the development of visual selective
attention. Our starting point is a study reported by Quittner,
Smilh, Osberger, Mitchell, and Katz (1994). They found that
profoundly deaf children performed substantially differently
Linda B. Smith and Alexandra L. Quittner, Department of Psychology,
Indiana University Bloomington; Mary Joe Osberger, Advanced Bionics
Corporation, Boston, Massachusetts; Richard Miyamoto, Department of
Otolaryngology, Indiana University School of Medicine.
This research was supported in part by Biomedical Research Grant
PHS RR7031-27, an Indiana University Intercampus Grant, and National
Institute on Deafness and Other Communication Disorders Grant DC
00064.
Correspondence concerning this article should be addressed to Linda
B. Smith, Department of Psychology Indiana University, Bloomington,
Indiana 47405. Electronic mail may be sent to smith4@indiana.edu.
from hearing children on visual selective attention tasks that
involved no sound. Moreover, they found that profoundly deaf
children who had access to auditory information through a co-
chlear implant performed more like hearing children. And, criti-
cally for the specific question we ask here, these differences
emerged and increased from younger to older children.
Quittner et al. (1994) used a continuous visual performance
task that involved no sounds at all. The task is one that has been
widely used to identify children with serious attentional deficits
in the clinical literature (Barkley, 1988; Gordon, 1986, 1987). It
requires sustained visual attention or vigilance over a fairly long
period of time, the discrimination of targets from nontargets,
and selective responding to the target information alone. More
specifically, children were presented with a continuous stream of
numbers and were asked to press a button whenever a sequence
of two digits ( " 1 " then " 9 " ) occurred in succession.
The children were grouped into two broad age ranges: 6- to
8-year-olds and 9- to 13-year-olds, and they fell into one of three
hearing-status groups: normally hearing children, severely to
profoundly deaf children, and profoundly deaf children who had
been using a cochlear implant for at least 1 year. A cochlear
implant is a device that digitizes sound and stimulates the co-
chlea at different points, providing direct input about acouslic
events (see Staller, Beiter, & Brimacombc, 1994). Thus, the
deaf children in this last group had, relative to the other deaf
children, enhanced access to auditory information.
Quittner et al. (1994) found an interaction between age and
hearing status. At the younger age level, both groups of deaf
children performed similarly and more poorly than the hearing
children. At the older age level, however, hearing children and
deaf children using cochlear implants performed well and much
better than the other deaf children. In contrast, older deaf chil-
dren without implants performed more poorly than even the
youngest hearing children. In brief, the deaf children had consid-
 AUDITION AND VISUAL ATTENTION
erable difficulty in a demanding visual selective attention task,
but older deaf children who used a cochlear implant appeared
to * 'catch up'' and performed as well as their hearing peers.
To our knowledge, Quittner et al.'s (1994) results are the first
experimental findings documenting the altered development of
visual selective attention in deaf children. This study, however,
follows a long line of anecdotal and clinical reports of atten-
tional problems in deaf children (R. I. Harris, 1978; Quittner,
Glueckauf, & Jackson, 1990). The clear implication is that ac-
cess to auditory information plays a role in the development of
selective attention. Results showing that older deaf children with
a cochlear implant perform similarly to hearing children further
supports the idea that access to sound benefits the development
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of visual selective attention. It is important that both samples
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of children (those with and without implants) in the Quittner
et al. sample were comparable: In their second experiment, the
children were recruited from the same otolaryngology clinic
and attended similar kinds of schools and language programs.
Thus, the effect of the implant on children's visual attention
does not appear to be due in any direct way to population
differences extraneous to the implant.
Why Should Deaf Children Perform Poorly
in This Attention Task?
One hypothesis often raised in the older literature on sensory
deficits suggests that deaf children are underaroused because of
a lack of stimulation (Levine, 1971). If deaf children's poor
selective attention stemmed from such underarousal, one might
hypothesize that the cochlear implant benefits attention by in-
creasing the quantity of sensory input and thus arousal. There
is, however, little support for this underarousal hypothesis in the
literature (see, e.g., Wood, 1991). Furthermore, two aspects of
Quittner et al.'s (1994) study suggest the implausibility of this
account. First, there were no observable differences in arousal
levels or task interest in the two groups of deaf children. Second,
both groups of deaf children in that study had auditory stimula-
tion during the course of the task—one group through a co-
chlear implant and the other group through hearing aids.
This is a potentially important point. Virtually all deaf chil-
dren use some type of sensory aid. And deafness, even profound
deafness, is neither uniform nor complete (Staller et al., 1994).
Thus, both the deaf children with hearing aids and those with
cochlear implants had access to auditory information—but the
nature of that information was very different. Hearing aids am-
plify a broad spectrum of frequencies with some temporal delay
and imprecision. In contrast, implants directly stimulate the au-
ditory nerve, presenting limited spectral information with fine-
grained temporal resolution. Thus, it would not seem to be
stimulation and arousal but the kind of auditory information
available that explains the results.
A second possibility concerns the role of language. Many
developmentalists have suggested that communication with oth-
ers and self is the process through which behavioral control and
selective attention develop (Berk, 1986; Luria, 1961; Vygotsky,
1962). Many deaf children (and all the deaf children in Quittner
et al.'s [1994] study) have hearing parents and thus diminished
communicative experiences early in lite. Therefore, these deaf
children might reasonably be expected to show an altered or
841
delayed course of attentional development. The problem with
this account is the good visual selective attention shown by the
older deaf children with cochlear implants. Although Quittner
et al. did not measure the deaf children's language skills, past
research comparing deaf children with and without implants
suggests that the deaf children in Quittner et al.'s study would
not differ in their language skills (Quittner et al., 1994).
A third possibility emerges from considering how seeing and
hearing normally interact in the control of visual attention. Hear-
ing individuals often use audition to monitor both their near and
their far world for changing events, while allowing vision to
focus narrowly on the task at hand. When a new event is signaled
by sound, they then shift visual attention appropriately. In con-
trast, deaf individuals must use vision both to monitor the world
for new events and to accomplish the immediate task (see Mitch-
ell, 1996; Mitchell & Smith, 1996; Neville, 1990). Thus, while
hearing individuals may develop a highly selective, task-oriented
visual attention, deaf individuals may adaptively develop a more
distributed visual attention. The advantage of a cochlear implant
for deaf children may be that it allows them to more effectively
use sound to monitor the environment for new information, thus
enabling visual attention to become more selective. This third
hypothesis motivated the present study.
Why Does a Cochlear Implant Benefit Older and Not
Younger Deaf Children's Selective Attention?
If an implant provides sufficient information for the develop-
ment of selective visual attention, why did only the older deaf
children with an implant show this advantage? One possibility
is that younger deaf children have difficulty learning to use their
implant, a training and adjustment process that typically takes
6 months (Osberger, 1986). There is, however, no evidence that
younger children have greater difficulty than older children with
this process (Staller et al., 1994). Moreover, all that is known
about perceptual learning would suggest that younger rather than
older children would more readily adapt to and learn to use the
new sensory input (see Aslin & Smith, 1988). Indeed, cochlear
implants are now being given to toddlers and preschoolers with
some success (Staller et al., 1994).
A second possibility is that the selective attention task used
by Quittner et al. (1994) is too difficult for younger children
and thus not sensitive to the potentially small gains in visual
attention made by younger deaf children using an implant. This
possibility is plausible given the difficulty of the task for all
young children, including hearing children. Moreover, because
the age groups in the Quittner et al. study were broad, it is
possible that there is some benefit to visual selective attention
from an implant that is being masked by the poor performance
of the very youngest children. We examined these two possibili-
ties in the present study by using finer age distinctions in Experi-
ment 1 and a simpler attention task than used by Quittner et al.
in Experiment 2.
A third and more theoretically interesting possibility is that
the influence of a cochlear implant on the development of visual
selective attention must wait until visual attention starts to de-
velop rapidly. An extensive literature on selective attention skills
in hearing children suggests that the time of most rapid change
begins around the ages of 5 to 7 years (Aslin & Smith, 1988).
 842 SMITH, QUITTNER, OSBERGER, AND MIYAMOTO
Findings from a variety of kinds of tasks including discrimina-
tive learning, classification, and speeded selective attention tasks
suggest dramatic improvements in children's ability to focus on
task-relevant information and ignore task-irrelevant informa-
tion. This period of time, concomitant with the start of school,
is known in some literatures as "the 5-to-7 shift" because of
the rapid development of such basic cognitive skills as selective
attention, strategic memory, and planful problem solving (see
Siegler, 1991).
These facts about the development of selective attention pro-
vided the impetus for the present study. Our specific goal was
to plot the developmental trajectory of visual selective attention
for hearing children and deaf children with and without cochlear
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implants. We ask whether advances in visual selective attention
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occur in the same way for all groups. Are there differences
among the groups in the timing of developmental change? Are
there differences in the magnitude of developmental change?
We address these questions in two experiments using cross-
sectional designs. The first tests children from 6 to 13 years of
age, and the second more closely examines children from 4 to
7 years of age.
Experiment 1
This experiment uses the same continuous visual performance
task used by Quittner et al (1994). Use of this task was moti-
vated by four considerations. First, the goal was to replicate the
Quittner et al. findings with a larger group of children. Second,
there are well-established performance norms on this task de-
rived from over 1,000 children ages 4 to 16 years (Gordon,
1987). Third, performance on this task has been shown to be
predictive of clinical levels of attention deficit disorder (Barkley,
1988). Fourth, Mitchell and Quittner (1996) showed that perfor-
mance in this task was predictive of behavioral problems of
deaf children both in the classroom and at home. The limitation
of this task and all continuous performance tasks is that they
do not provide a fine-grained measure of specific components
of attention. However, we believe that a global measure of the
developmental trajectory in a task predictive of real-world atten-
tional performance is the proper starting point for this line of
research.
As in the earlier Quittner et al. (1994) study, the present
study tested three groups of children: hearing children, deaf
children who used a cochlear implant, and a control group se-
lected from the larger population of deaf children. Because the
deaf children who elect to receive implants and their families
may differ from other deaf children, care was taken in the selec-
tion of the deaf control group to include two populations: deaf
children who were patients at the same medical facility as the
children who used implants and were under consideration for
an implant and deaf children who attended a residential school
for the deaf. The children in each group ranged in age from 6
to 13 years. In an effort to plot the developmental trajectory of
visual selective attention for each group, we used narrow age
groupings and a relatively large sample.
Method
Participants. The participants were 153 children. Of these, 51 were
deaf children who had received a cochlear implant and composed the
Table 1
Unaided Auditory Thresholds at Three Frequencies for Deaf
Children in Experiments 1 and 2
Cochlear implant Deaf control
Frequency (Hz) M SD M SD
Experiment 1
500 111.29 11.76 86.06 20.07
1000 116.93 8.36 96.94 18.54
2000 118.22 7.90 100.56 19.45
Experiment 2
500 102.51 6.41 73.10 24.11
1000 113.79 7.51 84.00 27,19
2000 113.75 7.48 88.02 30.52
cochlear implant (CI) group. These were deaf children who had received
a cochlear implant from the Department of Otolaryngology at the Indiana
University School of Medicine. All of these children were prelingually
and profoundly deaf (i.e., 90 dB loss or greater) as determined by
audiologists. Table 1 shows the mean unaided auditory threshold (i.e.,
widi implant turned off). These children had received their implants as
recently as 6 months prior to testing or as long as 6 years 6 months. The
implanted devices were of two types: single channel (i.e., 1 electrode,
3-M House; Fretz & Fravel, 1985) and multichannel (i.e., 22 electrodes,
Nucleus; Patrick & Clark. 1991). Of the 51 children in this group, 44
had received implants within the last 4 years and used the 22-channel
device, and 7 who had their implants longer used the single-channel
device. Children were tested during their regular visits to set and check
the device at the Department of Otolaryngology. As listed in Table 2,
these children had diverse educational experiences, including residential
programs, private day schools for the deaf, separate classrooms in the
public school, and regular public classrooms. Also listed in Table 2 is
the etiology of deafness, which is commonly unknown.
Fifty-one prelingually deaf children without implants were matched
to the CI group by age and composed the deaf control (DC) group.
Twenty-nine of these children were recruited from patients at the same
clinic and were being evaluated for or waiting to receive an implant at
the time of the test; these children were tested at the clinic during their
regular visits. Twenty-two children were recruited from and tested at
the Eastern North Carolina School for the Deaf. The mean unaided
auditory threshold for the children in the DC group is also provided in
Table 1. These thresholds are slightly better than the unaided thresholds
of children using cochlear implants. Of these 51 DC participants, 45
used a conventional hearing aid, and 6 used a vibrotactile aid (a device
that delivers acoustic energy to transducers worn on the skin; Franklin,
1991). Although many of these children used hearing aids, the unaided
auditory thresholds are such that even with a hearing aid, they receive
only minimal auditory information. Types of schooling, language train-
ing, and etiology of deafness for the children in this group are also listed
in Table 2.
Fifty-one hearing children matched in age to the children using co-
chlear implants were recruited from participant files maintained by the
developmental psychology program of the Department of Psychology of
Indiana University. These children composed the hearing control (HC)
group.
Task and procedure. Children were tested individually in a quiet
room. Deaf children were tested by one of three professionals fluent in
American Sign Language and Signed English. Instructions were pre-
sented to deaf children in the mode preferred by the participants. For
hearing children, instructions were in spoken English. Practice trials
 AUDITION AND VISUAL ATTENTION 843

Table 2 yielded main effects of group, F(2, 135) = 60.74, p < .001,
Demographic Characteristics of Children in Experiment 1 and age, F ( 5 , 135) = 15.87, p < .001, and an interaction
between Group X Age, F(10, 135) = 1.89, p = .05. Post hoc
Characteristic and type Cochlear implant Hearing aid Vibrotactile comparisons (Newman-Keuls, p < .05) indicated that at the
3 youngest three age levels, both groups of deaf children per-
Educational setting
Fully mainstreamed 10 3 0 formed reliably more poorly than did hearing children, and the
Remedial-resource 8 5 1 two groups of deaf children did not differ from each other.
Self-contained 19 5 2 However, for each of the older three age groups, children in the
Residential 9 19 3 CI group performed reliably better than did children in the DC
Day school 0 9 0
group.
Language modeb
Total communication 23 34 2 The shape of the age-related functions provides some insight
Oral 27 10 4 into these findings. The most marked gain in performance for
Etiology hearing children occurred between the ages of 7 and 8 years.
Unknown 23 25 1
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Meningitis 19 9 4 For both groups of deaf children, the most marked gains in
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Congenital 0 6 1 performance occurred between the 8-year-old group and the 9-

Genetic 4 5 0 year-old group. Thus, it would seem that gains in attentional
Mondini formation 2 0 0 skills emerge at about the same time, only slightly delayed in
Fistulas 1 0 0 deaf as compared with hearing children. However, although the
Ototoxicity 1 0 0
Measles vaccination 1 0 0
function for CI children began lower than that for DC children,
it showed rapid and more sustained gains from the period be-
" Five children with cochlear implants and 4 children with hearing aids tween 6 and 9 years. With age, differences between the CI group
had unknown educational settings. b One child with a cochlear implant and the DC group increased, and differences between the CI
and 1 child with a hearing aid had an unknown language mode. group and the HC group decreased. The difference between the
two groups of deaf children, then, appears not to be so much
in the timing of the developmental shift but in the magnitude of
preceded the test, and all participants performed perfectly on these trials, the developmental gain.
indicating that they understood that response to a " 9 " was conditional Relation to normative performance on this task. The contin-
on an immediately preceding " 1 . " uous performance task used in this study is widely used in the
On the test trials, children watched a stream of numbers on a CRT clinical literature to diagnose attention deficit disorder and has
screen at the rate of 1 per s, and each number was on the screen 0.2 s. been shown to be related to behavioral measures of attention
Children were instructed to push a button whenever a " 9 " appeared and distractibility (Barkley, 1992; Gordon, 1986; Mitchell &
after a *'l." Children thus had to respond selectively to " 9 " s preceded
Quittner, 1996). Gordon defined the abnormal range as perfor-
by " l " s and not respond to any other number nor to a " 9 " when it
was preceded by any other number. In total, a continuous stream of 540
mance at or below the 5th percentile of the normative sample.
numbers was presented such that 45 times in this stream, a " 9 " appeared No children in the HC group performed this poorly. In contrast,
after " 1 " ; 24 times, a " 9 " was preceded by another number; and thus
471 times, a number other than " 9 " appeared. Children were not given
feedback during the task. Table 3
Mean Hits (H) and False Alarms (F) as a Function
of Age in Experiment I
Results
Cochlear
The central question motivating this experiment was the shape implant Deaf control Hearing
of the developmental function in the continuous performance
task. Table 3 provides the mean hits—correct presses of the Age group H F H F H F
button, given a " 9 " after a " 1 " — a n d false alarms—incorrect
button presses to any other event in the sequence—for children 6-year-olds
M .58 .07 .69 .04 .89 .02
in the three groups as a function of age. We concentrated our SD .21 .08 .11 .19 .05 .01
analyses on d prime, which combines hits and false alarms to 7-year-olds
yield an unbiased estimate of a participant's ability to discrimi- M .67 .10 .69 .05 .88 .01
nate the target event ( " 9 " after " 1 " ) from all other events. SD .21 .07 .12 .42 .07 .02
8-year-olds
d prime. Each participant's d prime was calculated individ- M .73 .08 .68 .05 .94 .01
ually. Because of the nonlinearity of d prime, children who had SD .09 .02 .21 .30 .05 .01
no misses (a hit rate of 100%) had their hit rate set at .98 for 9-year-olds
the calculation of d prime. Thirteen hearing children and no M .87 .02 .77 .04 .96 .01
deaf children achieved this level of performance. Children who SD .08 .02 .21 .35 .04 .01
11 -year-olds
made no false alarms had their false-alarm rate set at .002 for M .92 .01 .86 ,11 .99 .01
determination of d prime; 8 HC children, 3 Cl children, and 1 SD .06 .01 .08 .25 .02 .01
DC child achieved this level of performance. 13-year-olds
Figure 1 shows mean d prime as a function of age for the M .95 .02 .88 .09 .98 .01
SD .05 .04 .12 .10 .04 .01
three groups of participants. The analysis of variance (ANOVA)
 SMITH, QUITTNER, OSBERGER, AND MIYAMOTO
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AGE (in years)
Figure 1. Mean d prime as a function of age for the three groups of
children in Experiment 1. CI = cochlear implant group; DC = deaf
control group; HC = hearing control group.
a substantial proportion of deaf children in both groups did so.
At the younger age levels, 6 to 8 years, 52% of the children
using cochlear implants and 26% of the children in the DC
group performed at or below the 5th percentile. At the older age
levels, 9 to 13 years, the performances of 18% of the children
using cochiear implants and 39% of the children in the DC
group fell in this range.
Length of time using a cochlear implant. If use of a cochlear
implant provides enhanced access to sound in ways that promote
the development of visual selective attention, then one might
expect that the length of use of the device would be correlated
with performance in the visual attention task. However, we found
no correlation between d prime and length of use of the implant
(r = .08). All children in this study had their implant at least
6 months. Thus, it may be that the gains in access to sound
relevant to visual attention occur rapidly postimplant (see Quitt-
ner et al., 1994).
Communication mode. As evident in Table 2, many children
in the CI group used primarily the oral mode of communication,
whereas the majority of children in the DC group used total
communication (TC). Mode of communication is a potential
force in the development of visual attention (see Neville &
Lawson, 1987). Effective lipreading requires focused attention
to small details; comprehending sign language also requires
skilled attention to rapid changes in complex visual events. Thus,
although it is not obvious a priori which mode of communication
might benefit the development of visual selective attention, it is
quite plausible that one mode might be more advantageous to
success in our task than the other.
To address this issue, we examined the performance of
younger (6-8-year-old) and older (9-13-year-old) children
in the CI group who used either oral communication or TC. The
mean d primes were 2.29 for younger oral children, 1,75 for
younger TC children, 3.40 for older oral children, and 3.38 for
older TC children. We submitted each rf-prime score for each
child in the CI group to a 2 (age) X 2 (mode) ANOVA. The
analysis revealed a highly reliable main effect of age, F{ 1, 46)
= 19.69, p< .01. Neither the effect of mode, F( 1,46) < 1.00,
nor the interaction, F{ 1, 46) < 1.00, approached significance.
Subgroups among the DC group. The DC group also con-
tained several subgroups whose performances we examined in-
dependently. First 28 of these children attended the same oto-
laryngology clinic as did the CI children and were like the CI
children in that they were from families interested in considering
an implant and in the mixed nature of their schooling experi-
ences. The remaining 23 deaf children were recruited from one
residential day school for the deaf and thus were immersed in
the language and culture of the deaf community. The perfor-
mances of these two groups of children in the visual attention
task as measured by d prime did not differ reliably; for the
clinic-tested children, the mean equaled 2.83; for the school-
tested children, the mean equaled 2.64, f(49) - 0.67.
Six of the clinic-tested children in the DC group used a vibro-
tactile aid rather than a hearing aid. Because this device provides
children with augmented access to sound, it is plausible that
a vibrotactile aid, like a cochlear implant, might benefit the
development of visual attention. There was no evidence for this
in our extremely small sample of children using the vibrotactile
aid. Their mean d prime in the continuous performance task
was 2.27, a level of performance comparable to the DC group
as a whole.
Summary, The results from Experiment 1 provide new in-
formation about the course of the development of visual selective
attention in the three populations.
First, the timing of major developmental change in this task
occurred between 7 and 9 years of age, with deaf children just
slightly delayed behind hearing children. Whatever the internal
or external factors relevant to the timing of age-related changes
in sustained selective attention, they appeared to operate simi-
larly across all the groups of children studied.
Second, the magnitude of age-related gains differed among
the groups. Children in the HC and DC groups showed similar
developmental functions, differing principally in the absolute
level of performance. CI children showed the largest and most
protracted gains, shifting from a level of absolute performance
comparable to the DC group to one that approached the HC
group. Moreover, where gains in performance were still evident
among the oldest CI groups, performance appeared to have
plateaued by 9 years of age in the DC group. These results
strongly suggest that access to sound in some way contributes
to the development of visual selective attention.
To gain further insight into this possibility, we conducted
Experiment 2. In this second experiment, we used a simpler
selective attention task to ask whether younger children using
a cochlear implant might show measurable gains in selective
attention earlier than suggested by the results of Experiment 1.
Experiment 2
In this experiment, we used a simplified version of the same
continuous performance task used in Experiment 1. In the clmi-
 AUDITION AND VISUAL ATTENTION 845

cal literature (Gordon, 1986), this simpler task is also widely Table 5
used to identify younger children with attentional deficits. In Mean Hits, False Alarms, d Primes, and Meaningful Auditory
this task, the child is asked to press a button whenever the digit Integration Scale (MAIS) Scores of Children in Experiment 2
" 0 " appears in a continuous stream. This, then, is a simple
Group
detection task—press whenever the target appears and do not
press otherwise. This task, however, requires sustained focused Hearing aid Cochlear implant
attention to the changing events on the CRT screen.
Variable M SD M SD
Method Correct responses
Participants. Thirty-six prelingually and severely to profoundly deaf (hit rate) .50 .29 .61 .27
children were recruited from the same otolaryngology clinic. As shown Incorrect responses
in Table 1, the unaided auditory thresholds were higher for the CI chil- (false alarms) .10 .09 .06 .06
d prime 1.49 0.98 2.02 0.90
dren than for the DC children. The CI group consisted of 18 children
MAISa
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4.14 3.63 9.53 3.44

who used a cochlear implant {M age = 67 months, range = 51-86
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months). These children had received their implants 6 months to 2 years a

Four children with hearing aids and 3 children with cochlear implants
prior to testing, and all used the newer 22-channel Nucleus device. The had unknown MAIS scores.
DC group consisted of 18 children selected to match the CI children in
age (M age = 66 months, range = 51-91 months). Fourteen of these
children used a hearing aid, and 4 used a vibrotactile device. The etiology
of deafness, schooling, and language modes in the two populations are 3. Turns to environmental sounds at home (e.g., doorbell, phone).
given in Table 4. 4. Responds to new sounds in unfamiliar settings (e.g., restaurant,
Procedure. Children were tested individually in a quiet room at the friend's home).
clinic by one of two professionals fluent in both American Sign Lan- 5. Shows some recognition of speech sounds from nonspeech sounds.
guage and Signed English, who gave instructions using total communica- 6. Shows some recognition of the emotion contained in a voice (anger,
tion. Practice trials preceded the test; performance on these trials indi- excitement).
cated that all participants understood the instructions—to respond to all
and only " 0 " s that appeared on the screen. On the test trials, children
watched a stream of numbers on a CRT screen at the rate of 1 per 2 s,
Results
and each number was on the screen for 0.2 s. In total, a continuous Table 5 shows the mean hits, false alarms, d primes, and
stream of 360 numbers were presented such that 30 times in this stream, questionnaire scores for the two groups of children. As is appar-
a " 0 " was presented. Children were not given feedback during the task.
ent, there were small group differences in the continuous perfor-
All parents of children in both groups were asked to fill out a question-
mance task. The two groups of children did not differ reliably
naire on their children's attention to environmental sounds adapted from
a questionnaire (Meaningful Auditory Integration Scale; MAIS) devised
(one-tailed) in hit rate (one-tailed), r(34) = 1.31,p < .10, nor
by Osberger (1986). Parents were specifically asked to rate on a 5-point false-alarm rate, f(34) < 1.00. Tn contrast, differences in d-
scale (0 = never to 4 = always) the degree to which statements per- prime scores did reach significance, £(34) = 1.69, p = .05.
taining to the following behaviors were characteristic of their child: Still, overall, young deaf children, both in the CI and the DC
1. Turns to look when name is called in a quiet room (and caller out groups, did not perform particularly well on this selective atten-
of sight). tion task. Six of 18 children in the CI group and 9 of 18 in the
2. Turns to look when name is called in a noisy room (and caller is DC group performed at or below the 5th percentile of the norma-
out of sight). tive sample for this task.
Figure 2 shows the relationship between individual partici-
pants' performances as measured by d prime and age. There
Table 4 was a strong relation between performance and age for both
Demographic Characteristics of Children in Experiment 2 groups. However, it was much stronger for the CI group {r -
Characteristic and type Cochlear implant Hearing aid Vibrotactile .74) than for the DC group (r = .54). Thus, although the
younger deaf children did not, as a group, perform well on this
Educational setting3 simpler task, we did sec incremental age-related growth and at
Fully mainstreamed 2 1 0 an earlier age than was evident in the harder lask of Experiment
Remedial-resource 1 3 0 1. Moreover, these changes were both greater and more consis-
Self-contained 8 7 4
Residential 2 2 0 tently related to age for children in the CI group. Gains in
Language modeb performance in the CI group were most evident as children
Total communication 7 8 2 approached 6 years of age.
Oral 8 5 2
As shown in Table 5, the two groups of deaf children did
Etiology
Unknown 12 10 0 differ markedly in parents' reports of their sensitivity to environ-
Meningitis 4 2 4 mental sounds, r( 27) = 4.10, p< .001, with children in the CI
Congenital 1 0 group being rated as more responsive to environmental sounds.
Generic 1 0 0 Although these parent ratings could have been influenced more
a
Five children with cochlear implants and 1 child with a hearing aid by parents' expectations and desires than by actual sensitivity
had unknown educational settings. b Three children with cochlear im- to environmental sounds, they appeared to have some validity,
plants and 1 child with a hearing aid had an unknown language mode. at least for the CT group, in that they were positively correlated
 846 SMITH, QUITTNER, OSBERGER, AND MIYAMOTO

DC Group CI Group
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

50 60 70 SO 90 100 50 60 70 80 90 100

Age (in months) Age (in months)

Figure 2. Scatter plot of the relation between each participant's d prime and age in Experiment 2, DC =
deaf control; CI = cochlear implant.

with performance in the visual attention task. Figure 3 shows
the scatter plots of individuals' d primes as a function of chil-
dren's scores on the MAIS. There was a reliable relation be-
tween the two measures for the CI children (r = .56, p < .05)
but not for the DC children (r = .30). Thus, enhanced sensitivity
to sound and visual selective attention appeared to change to-
gether in these younger deaf children with implants. These re-
sults, together with those of Experiment 1, suggest that sensitiv-
ity to environmental sounds is related to the beginning of devel-
opmental changes in the control of visual attention.
Just as in Experiment 1, for children in the CI group, there
was no relation between time with the implant and performance
on the task (r = .20). The lack of relation between participants'
performance on the task and length of time they had used an
implant device raises perplexing questions about just how and
why access to sound is related to visual selective attention. Our
results strongly suggest that the use of a cochlear implant leads
to the development of skilled visual attention, but our results
also suggest no relation between length of time an implant has
been used and success in the visual attention task. The CI chil-
dren and the DC children in this experiment were recruited from
the same population, and thus population differences seem an
unlikely source of the better task performance.
One possible explanation is that the relevant effects of implant
use occur rapidly postsurgery (see Quittner et al., 1994, for a
similar suggestion). We have some data pertinent to this issue-
Six children—4 participants from Experiment 1 and 2 partici-
pants from Experiment 2—were tested twice in the attention

DC Group CI Group

a.
a

5 10 5 10
Reported sensitivity to sound Reported sensitivity to sound

Figure 3. Scatter plot of the relation between each participant's d prime and parent report of the partici-
pant's sensitivity to sound in Experiment 2. DC = deaf control; CI - cochlear implant.
 AUDITION AND VISUAL ATTENTION
Q 2
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
48 60 71 84 96
Age at time of test in months
Figure 4. Data from 6 children who completed the Continuous Performance Test pre- and postimplant.
Each Hue indicates the d prime for an individual participant as a function of the age of that participant at
the preimplant and postimplant test.
task, once presurgery and once postsurgery. Thus, for these 6
children, we can report pre- and postimplant performance on
the visual attention task.
These 6 children's pre- and postimplant d primes are shown
in Figure 4. The graph shows performance as a function of the
age of the participant at the time of the test. The average time
between tests was 9 months, and the time between hookup of
the implant device and the second test in our task was 6 months
for all children. As is apparent, performance on the visual atten-
tion task postimplant increased for 5 of the 6 children and did
so quite dramatically for 3 of them. One cannot make strong
conclusions from these results because of the small number of
participants and because we have no control for the effects of
repeated testing. However, these data are consistent with the
idea that the relevant effects of the implant can be rapid; these
effects are apparently not realized in successful task perfor-
mance until a certain point in development is attained.
General Discussion
We asked in our introduction to this article why deaf children
should perform poorly on visual attention tasks. The answer to
this question will provide important insights into development
in the deaf population as well as into the processes that underlie
the development of attention more generally. Our goal was to
provide evidence relevant to this question by examining the
course of age-related changes across three groups of children:
hearing children, deaf children, and deaf children with enhanced
access to sound through a cochlear implant.
The results of Experiment 1 suggest that the timing of devel-
opmental change was similar across the three groups. The timing
847
108 120 132 144 156 168 180
of greatest gain occurred about I year earlier for hearing chil-
dren than for children in both deaf groups. The fact that the
timing of developmental change was similar for all groups pro-
vides new information about the development of attention and
its relation to hearing. Whatever the control parameter that orga-
nizes change at this developmental point, it is apparently inde-
pendent of access to sound. The timing of developmental change
in all three populations might be controlled by internal factors
such as the maturation of inhibitory processes in the frontal
lobe (see, e.g., Diamond, 1990). Alternatively, the timing of
developmental change might be externally driven, perhaps by
the increased demands of schooling in early childhood. Either
way, the timing of the developmental shift in this continuous
performance task was altered only slightly by deafness.
In contrast, the level of overall performance and the magni-
tude of developmental change appear to be strongly dependent
on the kind of access to sound. The results of Experiment 1
indicated dramatic differences in the magnitude of age-related
change among the three groups of children, hunger deaf chil-
dren using a cochlear implant performed most poorly and con-
siderably less well than hearing children. However, between the
ages of 8 and 9, performances by children in this group shifted
to approach that of their hearing peers. Performances by children
in the deaf control group increased to a much lesser degree.
Indeed, performance for this group appeared to asymptote at a
level below that of the youngest hearing children. The results
of Experiment 2 further suggest that there are beginning signs
of the attentional differences to come at earlier ages: hunger
children in the CI group showed both more sensitivity to envi-
ronmental sounds and slightly better performance on a simpler
visual attention task.
 SMITH, QUITTNER, OSBERGER, AND MIYAMOTO

This pattern of results suggests that highly selective visual Hypothetical Trajectories
attention is the product of a complex system that includes multi-
Component 1 — selectivity
ple components. Our results provide hints toward the nature of
this system and its dependence on sound. The first clue is the — Component 2 — access to sound
strong relationship between performance and age. Whatever
sound a cochkar implant provides, it is nol well used in the — Performance in Task
service of visual attention until 8 or 9 years of age. The second
clue is that gains in selective attention as a consequence of a
child's using a cochlear implant happen within months of receiv-
ing the implant. Hearing
child

Sound as an Enabling Condition

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These two facts suggest a model of attentional development

This document is copyrighted by the American Psychological Association or one of its allied publishers.

in which access to sound is an enabling condition for the devel-

opment of selective attention. We attempt to clarify this proposal
in Figure 5. The top of Figure 5 shows hypothetical develop-
Deaf
mental trajectories for two possible components critical to suc- child
cessful selective attention as they might develop in hearing chil-
dren. Component 1 might be the ability to select task-relevant
visual information (or inhibit irrelevant visual information).
Component 2 might be the availability of sounds that predict
visual events. Component 2 is fully developed even in young
hearing children because they have access to the critical auditory
information. Thus, hearing children's performance in selec-
Deaf child
tive attention tasks will be limited by the development of Com- with early
ponent 1. implant
The same two hypothetical trajectories are shown for the deaf
control children in the middle panel. If success in visual selec-
tive attention tasks requires both components, then these chil- I
dren's performance will be limited because they lack Compo-
nent 2, the requisite access to sound. Finally, the bottom two
panels show the two hypothetical trajectories for Component 1
and Component 2 for deaf children who have received a cochlear
Deaf child
implant—1 at age 5 and 1 at age 13 years. The 5-year-old, with late
despite the requisite access to sound, will not demonstrate highly implant
selective visual attention—as 5-year-old hearing children do
not—because Component 1 has not developed to a sufficient
degree. In contrast, the 13-year-old might show rapid gains in
visual selective attention postimplant because this child has the Figure 5. Hypothetical developmental trajectories of two component
requisite skills of Component 1 but needs the enabling condition abilities and task performance for 4 hypothetical children. See text for
of sound to use them. clarification.

The present pattern of results strongly suggests a multicompo-

nent model of this sort. Unclear at present, however, is just what
these components are and how sound functions as a critical
enabling condition. One possibility suggested by Mitchell
(1996; see also Swisher, 1989) is that deaf and hearing individu-
als develop different solutions to the general attentional problem
of focusing on specific tasks while monitoring the world for
upcoming events. She noted that highly selective attention is
maladaptive. Attention should not be so completely engrossed
by a narrow task that one is unaware of the occurrence of
potentially important (even harmful) events. Multimodal contact
with the world allows a kind of division of labor. Hearing indi-
viduals can attend quite selectively to a narrow visual field
and still monitor the broader environment through sound. Deaf
individuals, in contrast, must simultaneously use vision both to
accomplish specific tasks and to monitor the broader environ-
ment for changing events. Mitchell suggested that deaf individu-
als develop a more spatially distributed visual attention and
enhanced detection of changes in the peripheral visual field
(for supporting empirical evidence, see Neville, 1990; Swisher,
1989). Deaf children, then, may perform more poorly in labora-
tory tasks because in the larger attentional field of everyday life,
distributed visual attention is more adaptive. Thus, access to
sound may be an enabling condition because it frees up visual
attention, allowing it to become task specific.
Division-of-Labor Hypothesis
The model outlined in Figure 5 and Mitchell's (1996) divi-
sion-of-labor hypothesis fit several aspects of the present data
through the following findings: that children using a cochlear
implant are reported to attend to unexpected environmental
 AUDITION AND VISUAL ATTENTION
sounds, that this responsiveness is correlated with the improve-
ments of younger children in a simpler attention task, and finally,
that gains in visual selective attention among older children do
not require extended use of the implant device. Suggestive as
these data are, the model in Figure 5 and the division-of-labor
hypothesis clearly need more direct empirical support. Still, the
present results point to an attentional system made up of many
developing and interacting components.
Another pressing question for future work is the precise na-
ture of the sound that is necessary for the development of good
selective attention. Deaf children without cochlear implants have
some access to sound and typically use some device such as a
hearing aid to bolster auditory input. Why, then, is the auditory
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information provided by a cochlear implant sufficient for the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
development of good visual selective attention but that provided
by a hearing aid is not? Clearly, one difference is that given the
degree of deafness, the hearing aid may be providing in many
cases only the most minimal access to sound. There are several
other differences between the nature of the auditory input in the
two cases that are also worth noting. First, the implanted device
directly stimulates the auditory nerve bypassing the inner ear;
hearing aids, in contrast, work through the inner ear. This is
critical because the inner ear is often damaged in deaf individu-
als and may not transduce all of the information (Staller et al.,
1994). Second, the auditory signal provided by cochlear im-
plants has fine temporal resolution, finer than that available
from a hearing aid that provides noisy transduction through the
inner ear. This may be particularly critical if the gains in visual
selective attention rely on temporal correlations between sights
and sounds. Third, there could be some advantage to direct
electrical stimulation of the auditory nerve. For example, direct
stimulation could more vigorously alert the perceptual-atten-
tional system than the compromised acoustic signal provided
by the hearing aid.
Development of Visual Selective Attention
Without Sound
Hearing children and many deaf children, particularly those
with hearing parents, grow up in a social world organized by
both sights and sounds. Our results suggest that in this
multimodal ecology, access to sound plays a role in the develop-
ment of visual attention. There are, however, deaf children, par-
ticularly those with deaf parents, who grow up in a social world
in which sound matters much less. Growing research suggests
that deaf parents of deaf children are skilled in organizing their
children's attention during social interaction and do so in ways
that are not typical of hearing parents of deaf children (sec M.
Harris, CHbbens, Chasin, & Tibbitts, 1989; Swisher, 1991,
1992). For example, deaf parents of deaf children cue the need
to shift gaze by touching, by waiting until the child looks to
where the adult looks, by flicking lights, and by stamping on
the floor. It is possible that these systematic cues may present
an ecology in which highly selective visual attention can de-
velop. In other words, although access to sound may play a
critical role in the development of visual attention in typically
developing children, there may be alternate routes—those that
do not include access to sound—to the same end.
849
In summary, the present results provide new information
about the development of visual selective attention generally
and also about its development in deaf children. Attentional
development has broad implications for other achievements in
the deaf population, such as reading, conceptual thinking, and
classroom performance (Quittner et al., 1990). One relevant
issue is increased impulsivity and distractibility reported in deaf
children. Indeed, the ability to focus attention in this laboratory
task has been shown to be related to classroom behavior and
behavioral problems at home (Mitchell & Quittner, 1996). Un-
derstanding how visual selective attention comes to be organized
and the role of sound in that organization may ultimately enable
us to affect the behavioral development of deaf children.
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Received March 27, 1997
Revision received December 22, 1997
Accepted December 23, 1997 •

Correction to Schwanenflugel et al. (1998)

In the article "Developing Organization of Mental Verbs and Theory of Mind in Middle Child-
hood: Evidence From Extensions," by Paula J. Schwanenflugel, Robbie L. Henderson, and William
V. Fabricius (Developmental Psychology, 1998, Vol. 34, No. 3, pp. 512-524), Figures 2 and 4 were
inadvertently switched. The figure appearing on page 519 is Figure 4, and the data pertain to third
graders; the figure appearing on page 521 is Figure 2, and the data pertain to adults.