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We examined the impact of exposure to a signed language (American Sign Language, or ASL) at different ages on the neural systems that support spoken language phonemic discrimination in deaf individuals with cochlear implants (CIs). Deaf CI users (N = 18, age = 18-24 yrs) who were exposed to a signed language at different ages and hearing individuals (N = 18, age = 18-21 yrs) completed a phonemic discrimination task in a spoken native (English) and non-native (Hindi) language while undergoing functional near-infrared spectroscopy neuroimaging. Behaviorally, deaf CI users who received a CI early versus later in life showed better English phonemic discrimination, albeit phonemic discrimination was poor relative to hearing individuals. Importantly, the age of exposure to ASL was not related to phonemic discrimination. Neurally, early-life language exposure, irrespective of modality, was associated with greater neural activation of left-hemisphere language areas critically involved in phonological processing during the phonemic discrimination task in deaf CI users. In particular, early exposure to ASL was associated with increased activation in the left hemisphere's classic language regions for native versus non-native language phonemic contrasts for deaf CI users who received a CI later in life. For deaf CI users who received a CI early in life, the age of exposure to ASL was not related to neural activation during phonemic discrimination. Together, the findings suggest that early signed language exposure does not negatively impact spoken language processing in deaf CI users, but may instead potentially offset the negative effects of language deprivation that deaf children without any signed language exposure experience prior to implantation. This empirical evidence aligns with and lends support to recent perspectives regarding the impact of ASL exposure in the context of CI usage.

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The hypothesis that impoverished language experience affects complex sentence structure development around the end of early childhood was tested using a fully randomized, sentence-to-picture matching study in American Sign Language (ASL). The participants were ASL signers who had impoverished or typical access to language in early childhood. Deaf signers whose access to language was highly impoverished in early childhood (N = 11) primarily comprehended structures consisting of a single verb and argument (Subject or Object), agreeing verbs, and the spatial relation or path of semantic classifiers. They showed difficulty comprehending more complex sentence structures involving dual lexical arguments or multiple verbs. As predicted, participants with typical language access in early childhood, deaf native signers (N = 17) or hearing second-language learners (N = 10), comprehended the range of 12 ASL sentence structures, independent of the subjective iconicity or frequency of the stimulus lexical items, or length of ASL experience and performance on non-verbal cognitive tasks. The results show that language experience in early childhood is necessary for the development of complex syntax. RESEARCH HIGHLIGHTS: Previous research with deaf signers suggests an inflection point around the end of early childhood for sentence structure development. Deaf signers who experienced impoverished language until the age of 9 or older comprehend several basic sentence structures but few complex structures. Language experience in early childhood is necessary for the development of complex sentence structure.

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Due to the ubiquitous nature of language in the environment of infants, how it affects the anatomical structure of the brain language system over the lifespan is not well understood. In this study, we investigated the effects of early language experience on the adult brain by examining anatomical features of individuals born deaf with typical or restricted language experience in early childhood. Twenty-two deaf adults whose primary language was American Sign Language and were first immersed in it at ages ranging from birth to 14 y participated. The control group was 21 hearing non-signers. We acquired T1-weighted magnetic resonance images and used FreeSurfer [B. Fischl, Neuroimage 62, 774-781(2012)] to reconstruct the brain surface. Using an a priori regions of interest (ROI) approach, we identified 17 language and 19 somatomotor ROIs in each hemisphere from the Human Connectome Project parcellation map [M. F. Glasser et al., Nature 536, 171-178 (2016)]. Restricted language experience in early childhood was associated with negative changes in adjusted grey matter volume and/or cortical thickness in bilateral fronto-temporal regions. No evidence of anatomical differences was observed in any of these regions when deaf signers with infant sign language experience were compared with hearing speakers with infant spoken language experience, showing that the effects of early language experience on the brain language system are supramodal.

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INTRODUCTION: Children who are deaf or hard of hearing (DHH) are at risk for poor developmental outcomes related to incomplete language access. Evidence based interventions are available to improve early access to language. With a better understanding of caring for DHH children, pediatricians will be more prepared to work with families in improving outcomes for this population. To date, there are no formal curricula on educating pediatric trainees on childhood hearing differences. METHODS: The authors designed a novel pilot curriculum to educate pediatric trainees on caring for DHH children, including screening, diagnosis, signed languages, and hearing technologies. The curriculum was delivered to pediatric interns in a 1-hour seminar. Pre-lecture, immediate post-lecture, and 6-month post-lecture surveys were developed and conducted to evaluate the effectiveness of the curriculum. Descriptive statistics were used to determine differences in understanding concepts before and after the curricular intervention. RESULTS: A total of 55 residents participated in the curriculum over a 14-month study period from 2018 to 2019. There were significant differences in responses between the pre- and post- surveys related to residents' understanding of childhood deafness and their confidence in their ability to care for DHH children. CONCLUSION: Pediatric trainees gained an understanding of the challenges faced by DHH children and of the interventions that aim to provide them with access to language during the critical period of development. As a result, trainees will be in a better position to care for patients and their families after a new diagnosis of a hearing difference and guide them through early language-based interventions.

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Natural sign languages of deaf communities are acquired on the same time scale as that of spoken languages if children have access to fluent signers providing input from birth. Infants are sensitive to linguistic information provided visually, and early milestones show many parallels. The modality may affect various areas of language acquisition; such effects include the form of signs (sign phonology), the potential advantage presented by visual iconicity, and the use of spatial locations to represent referents, locations, and movement events. Unfortunately, the vast majority of deaf children do not receive accessible linguistic input in infancy, and these children experience language deprivation. Negative effects on language are observed when first-language acquisition is delayed. For those who eventually begin to learn a sign language, earlier input is associated with better language and academic outcomes. Further research is especially needed with a broader diversity of participants.

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Early language acquisition is critical for lifelong success in language, literacy, and academic studies. There is much to explore about the specific techniques used to foster deaf children's language development. The use of rhyme and rhythm in American Sign Language (ASL) remains understudied. This single-subject study compared the effects of rhyming and non-rhyming ASL stories on the engagement behavior and accuracy in recitation of five deaf children between three and six years old in an ASL/English bilingual early childhood classroom. With the application of alternating treatment design with initial baseline, it is the first experimental research of its kind on ASL rhyme and rhythm. Baseline data revealed the lack of rhyme awareness in children and informed the decision to provide intervention as a condition to examine the effects of explicit handshape rhyme awareness instruction on increasing engagement behavior and accuracy in recitation. There were four phases in this study: baseline, handshape rhyme awareness intervention, alternating treatments, and preference. Visual analysis and total mean and mean difference procedures were employed to analyze results. The findings indicate that recitation skills in young deaf children can be supported through interventions utilizing ASL rhyme and rhythm supplemented with ASL phonological awareness activities. A potential case of sign language impairment was identified in a native signer, creating a new line of inquiry in using ASL rhyme, rhythm, and phonological awareness to detect atypical language patterns.

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Language deprivation syndrome (LDS) is a permanent and preventable disability affecting language, cognition, and behavior that is epidemic in the deaf population. Since 1990, systemic and technological changes in the health care of deaf children have created a new paradigm that perpetuates this crisis. Physicians and other professionals have been largely unaware of their roles in this recent epidemic. An evidenced based system of care that addresses the causes and potential solutions can reverse this trend and prevent early language deprivation in deaf children.

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PURPOSE: Many deaf children have limited access to language, spoken or signed, during early childhood - which has damaging effects on many aspects of development. There has been a recent shift to consider deafness and language deprivation as separate but related conditions. As such, educational plans should differentiate between services related to deafness and services related to language deprivation. DESCRIPTION: Many deaf children attend mainstream public schools, and the primary service offered to students who use American Sign Language (ASL) is generally a sign language interpreter. ASSESSMENT: We argue that while sign language interpreters can be an effective accommodation for deafness (i.e., students who are deaf and not language-deprived), there is no reason to believe they are an effective accommodation for language deprivation (i.e., students who are deaf and language-deprived). CONCLUSION: Using interpreters instead of appropriate educational supports may exacerbate symptoms of language deprivation by prolonging the period of time a child goes with limited access to language.

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Vocabulary is a critical early marker of language development. The MacArthur Bates Communicative Development Inventory has been adapted to dozens of languages, and provides a bird's-eye view of children's early vocabularies which can be informative for both research and clinical purposes. We present an update to the American Sign Language Communicative Development Inventory (the ASL-CDI 2.0,  https://www.aslcdi.org ), a normed assessment of early ASL vocabulary that can be widely administered online by individuals with no formal training in sign language linguistics. The ASL-CDI 2.0 includes receptive and expressive vocabulary, and a Gestures and Phrases section; it also introduces an online interface that presents ASL signs as videos. We validated the ASL-CDI 2.0 with expressive and receptive in-person tasks administered to a subset of participants. The norming sample presented here consists of 120 deaf children (ages 9 to 73 months) with deaf parents. We present an analysis of the measurement properties of the ASL-CDI 2.0. Vocabulary increases with age, as expected. We see an early noun bias that shifts with age, and a lag between receptive and expressive vocabulary. We present these findings with indications for how the ASL-CDI 2.0 may be used in a range of clinical and research settings.

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Previous research has identified ventral and dorsal white matter tracts as being crucial for language processing; their maturation correlates with increased language processing capacity. Unknown is whether the growth or maintenance of these language-relevant pathways is shaped by language experience in early life. To investigate the effects of early language deprivation and the sensory-motor modality of language on white matter tracts, we examined the white matter connectivity of language-relevant pathways in congenitally deaf people with or without early access to language. We acquired diffusion tensor imaging (DTI) data from two groups of individuals who experienced language from birth, twelve deaf native signers of American Sign Language, and twelve hearing L2 signers of ASL (native English speakers), and from three, well-studied individual cases who experienced minimal language during childhood. The results indicate that the sensory-motor modality of early language experience does not affect the white matter microstructure between crucial language regions. Both groups with early language experience, deaf and hearing, show leftward laterality in the two language-related tracts. However, all three cases with early language deprivation showed altered white matter microstructure, especially in the left dorsal arcuate fasciculus (AF) pathway.

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Previous studies suggest that age of acquisition affects the outcomes of learning, especially at the morphosyntactic level. Unknown is how syntactic development is affected by increased cognitive maturity and delayed language onset. The current paper studied the early syntactic development of adolescent first language learners by examining word order patterns in American Sign Language (ASL). ASL uses a basic Subject-Verb-Object order, but also employs multiple word order variations. Child learners produce variable word order at the initial stage of acquisition, but later primarily produce canonical word order. We asked whether adolescent first language learners acquire ASL word order in a fashion parallel to child learners. We analyzed word order preference in spontaneous language samples from four adolescent L1 learners collected longitudinally from 12 months to six years of ASL exposure. Our results suggest that adolescent L1 learners go through stages similar to child native learners, although this process also appears to be prolonged.

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PURPOSE: There is a need to better understand the epidemiological relationship between language development and psychiatric symptomatology. Language development can be particularly impacted by social factors-as seen in the developmental choices made for deaf children, which can create language deprivation. A possible mental health syndrome may be present in deaf patients with severe language deprivation. METHODS: Electronic databases were searched to identify publications focusing on language development and mental health in the deaf population. Screening of relevant publications narrowed the search results to 35 publications. RESULTS: Although there is very limited empirical evidence, there appears to be suggestions of a mental health syndrome by clinicians working with deaf patients. Possible features include language dysfluency, fund of knowledge deficits, and disruptions in thinking, mood, and/or behavior. CONCLUSION: The clinical specialty of deaf mental health appears to be struggling with a clinically observed phenomenon that has yet to be empirically investigated and defined within the DSM. Descriptions of patients within the clinical setting suggest a language deprivation syndrome. Language development experiences have an epidemiological relationship with psychiatric outcomes in deaf people. This requires more empirical attention and has implications for other populations with behavioral health disparities as well.

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A long-standing belief is that sign language interferes with spoken language development in deaf children, despite a chronic lack of evidence supporting this belief. This deserves discussion as poor life outcomes continue to be seen in the deaf population. This commentary synthesizes research outcomes with signing and non-signing children and highlights fully accessible language as a protective factor for healthy development. Brain changes associated with language deprivation may be misrepresented as sign language interfering with spoken language outcomes of cochlear implants. This may lead to professionals and organizations advocating for preventing sign language exposure before implantation and spreading misinformation. The existence of one-time-sensitive-language acquisition window means a strong possibility of permanent brain changes when spoken language is not fully accessible to the deaf child and sign language exposure is delayed, as is often standard practice. There is no empirical evidence for the harm of sign language exposure but there is some evidence for its benefits, and there is growing evidence that lack of language access has negative implications. This includes cognitive delays, mental health difficulties, lower quality of life, higher trauma, and limited health literacy. Claims of cochlear implant- and spoken language-only approaches being more effective than sign language-inclusive approaches are not empirically supported. Cochlear implants are an unreliable standalone first-language intervention for deaf children. Priorities of deaf child development should focus on healthy growth of all developmental domains through a fully-accessible first language foundation such as sign language, rather than auditory deprivation and speech skills.

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Working with individuals who are deaf in mental health settings can be complex work, necessitating consideration for the difference in language abilities. These differences include not only the language differences of American Sign Language (ASL) and English, but also the range of heterogeneity within the Deaf Community. Multiple influences such as mental illness, medical conditions, language deprivation and the etiology of deafness can impact how a person acquires and uses language. This article will discuss how various causes of deafness create the potential for specific language dysfluencies with individuals who are deaf in mental health settings. The article will also discuss the use of communication assessments to examine specific language dysfluency patterns and attempt to offer possible corresponding interventions.

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