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ShouldAllDeafChildrenLearnSignLanguage?NancyK.Mellon,MS,JohnK.Niparko,MD,ChristianRathmann,PhD,GauravMathur,PhD,TomHumphries,PhDDonnaJoNapoli,PhD,TheresaHandley,BA,SashaScambler,PhD,JohnD.Lantos,MDabstract ETHICSROUNDSPEDIATRICSVolume136,number1,July2015 at National Institutes of Health Library on June 16, 2015pediatrics.aappublications.orgDownloaded from Diego;andDonnaJoNapoli,PhD,professoroflinguistics,andTheresaHandley,bothofSwarthmoreCollege.JohnD.LantosdirectstheChildrensMercyHospitalBioethicsCenter.Noneoftheauthorsisachildoradolescent.TheviewsofadolescentscanbefoundinChristiansians2014paper.Threeofourexpertsaredeafprofessionals.Threeofthemareparentsofprofoundlydeafchildren,2ofwhomhavebilateralCIs.Increatingthisarticle,theseexpertsreviewedeachotherscommentsandconsultedviaelectroniccommunication.THECASEAnewbornisidentiedashavingsensorineuraldeafness.Theparentshavenormalhearingandnoknowledgeofsignlanguage.Ahearingaidisnotmedicallyindicated.TheyhaveafewmonthstodecidewhethertooptforaCI.Inthemeantime,shouldtheylearnasignlanguageandbegintocommunicatewiththeirchildbyusingthatsignlanguage?IftheyeventuallyoptforaCI,shouldtheycontinuetosign?NANCYK.MELLON,MS,ANDJOHNK.NIPARKO,MD,COMMENTS:Parentsoftenviewthediagnosisofachildsdeafnessthroughaprismdeterminedbytheirownhearingstatus.Parentswhoaredeafmayviewthediagnosisthroughaculturallens,welcomingachildwhocaneasilysharetheirlanguageandculture.However,95%ofdeafchildrenareborntohearingparents.Hearingparentstypicallythinkofdeafnessasadisability.Theirviewsareshapedbytheirdesiretosharetheirownlanguageandculturewiththeirchild.Adeafchildborntohearingparentsandunabletogainmeaningfulspeechrecognitionfromhearingaidswilltypicallymeetthecriteriaforearlycochlearimplantation.TheUSFoodandDrugAdministrationapprovedthemultichannelCIforchildrenin1990.Almost100000childrenhaveusedCIssuccessfullytodevelopspokenlanguage.However,aCIcanenablestrongspokenlanguageonlywhenusedwithintensiveauditory-oralexposureinextended,salient,andchild-initiatedinteractions.Withoutafulllinguisticandauditoryexperience,theeffectsofdeafness-associateddeprivationcanderailthespokenlanguagelearningprocessbeforeitbegins.Thetimingofinterventioniscritical.Aninfantsnervoussystemisgeneticallypredisposedtoacceptonlyalimitedrangeofpotentialstimulitodrivethedevelopmentallearningoflanguage.Experiencesthatproducelanguageoccurinabiologicallyexpensive”periodinwhichneuralcircuitsareundecidedyetamenabletocommitment.Duringthissensitiveperiod,useofneuralcircuitsgeneratestheimpulsetrafcthatdifferentiatesneuraldevelopment.Ifachildmissestheneededexperienceswithinanoptimaltimeframe,essentialelementsinthatchildemergentlanguage,eitherspokenorsigned,maybemissing.ShouldaparentusesignlanguagewithayoungchildwhowillreceiveaCI?AsreviewedbyGeersetal,case-seriesreportsaremixedontheeffectsofsignlanguagebeforeimplantation.Wesuggestthatearlysignlanguage,whenusedforashorttimepreimplantasabridgetospokenlanguage,cannothurtandmaybecial.Earlyexperiencewithsignlanguagemaysupportachildparticipationinthekindofbidirectionalparentinteractionsthatformthefoundationoflanguagelearning,forexample,byenablingjointattention.However,animportantcaveatshouldbeconsidered.Theuseofanyresidualhearingshouldbemaximized.Datafromaprospective,nationaltrialinprogressindicatethatverballanguagelearnedbeforecochlearimplantationisassociatedwithacceleratedratesofspokenlanguagelearningafterimplantation.ForachildwhoreceivesaCI,thetimelyactivationofthedevicebeginsafullerexperiencewithsound.Relianceonsignlanguageoveranextendedperiodoftimemaynegativelyaffectthechildscapacitytolearnspokenlanguageaftercochlearimplantation.Prolonged,inadequateauditoryinputthatfailstosupportspokenlanguagelearningatage-appropriateratesisrelatedtogapsinspeechandlanguageaftercochlearimplantation.Importantly,evenextensiverehabilitativeeffortswillnotproducethelanguagesophisticationthatcanbeachievedbyexposuretospokenlanguageduringsensitiveperiodsofdevelopment.Achildsabilitytosuccessfullyacquirespokenlanguagerequiresaframeworkofrich,bidirectionalcommunicationwithlanguagementorsandimmersioninanorallanguageenvironment.BecausetheCIisdesignedtoequipachildwithskillstocommunicateinahearingworld,westronglyadvocateforeducationalprogramsthatallowchildrentoaccessthepragmaticsofspokenlanguageininteractionswiththeirhearingpeers.Althoughsignlanguagecanpromoteearlyparentchildcommunication,thefocusofinterventionshouldimmediatelyshifttohighlightingtheacousticpropertiesofspeechasconsistentlyaspossibleaftercochlearimplantationtooptimizeachildabilitytotalkandlisten.SASHASCAMBLER,PHD,COMMENTS:Iwriteasahearingparentofaprofoundlydeafchild.Iamalsoamedicalsociologist.Untilthelastfewdecades,therewerefewchoicestobemadebyhearingparentsofdeafchildren.Today,withCIsandwiththesuccessfulintroductionofnewbornhearingscreeningprograms,infantsarePEDIATRICSVolume136,number1,July2015 at National Institutes of Health Library on June 16, 2015pediatrics.aappublications.orgDownloaded from diagnosedwithintherstfewweeksoftheirlives,andtheycanreceiveaCIwellbeforetheirrstbirthday.IfparentsdecideaCIistheoptiontopursue,therstfewmonthsoftheslifearethenoccupiedwithtests,suitabilityassessments(forboththeparentsandchildren),andmedicalexaminations.Ifthechildisfoundtobeasuitablerecipient,theparentsthenfacethephenomenallycultdecisionaboutwhethertohavetheirchildundergoimplantationwiththeknowledgethatthereisnoguaranteethattheimplantwillworkorthatitwillresultinclear,intelligiblespeech.Parentsareaskedtodecidewhethertosubjecttheirchildtoalongoperationwithalloftheassociatedrisksandwithnoguaranteeofsuccess.Parentsarealsooftentoldthatitwouldbebestfortheirchildifthey,theparents,wouldlearnacompletelynew,alienlanguage.Signlanguageisclearlybenecialfordeafchildren,butfamiliesneedtimeandspacetoadjustandcometotermswitheverythingthatishappeningtothemandtotherealityofbeingtheparentsofadeafchild.AsthehearingparentofaprofoundlydeafsonwithbilateralCIs,thisissueisclosetomyheart.MysonhashadhisCIsfor5years.Hehasage-appropriateoral/aurallanguageskillsandattendsamainstreamprimaryschoolwithsupportfromaspecialistteacherforthedeaf.DespitehisCIsandspokenlanguageskills,heremainsdeafandalwayswillbe.Therearetimeswhenmysonisunabletowearhisimplantsorisunabletohearbecauseofexcessivebackgroundnoise.CIshavethesamelimitationsasotherarticialhearingdevices;theyworkbestincloserangewithlittlebackgroundnoise.Giventheselimitations,itisessentialthatwehaveameansofcommunicatingwithhim,andhewithus,whenhearingisnotanoption.Researchsuggeststhatspeechreading(lipreadingplusfacialexpression)canbeausefuladditionaltoolbutwillonlyresult,atbest,in60%accuracywithEnglishlanguage.AnalternativeformofcommunicationisthereforeSignlanguageisausefultoolforthefamilyofadeafchildregardlessofwhetherthechildisabletomakefulluseofCIs.Learningsignlanguageasahearingfamilyisnotwithoutproblems,however.OncethechildhashadhisorherCIactivated,thefamilywillbesurroundedbyprofessionalsgivingadviceonlanguagedevelopment,listeningskills,waystoprovidealanguage-richenvironment,andmethodsofmaximizingthepotentialofthetechnologythechildhasbeenprovidedwith.Fittingsigningintoanalreadyfullscheduleisdifcult.Thisadditionalresponsibilityisbeforemeetingtheneedsofotherchildrenwithinthefamilyaswellasonesownprofessionalandcareerobligations.Anotherimportantfactoristhatthelevelofsigningsupportavailabletofamiliesdependsontheareainwhichtheylive.Signlanguagelessonscanbeexpensiveifnosubsidiesareavailable.Signingclubscanalsobeintimidatingplacesforhearingfamilies.SomepeopleinthedeafcommunityareovertlyhostiletoCIWe,asafamily,areintheprocessoflearningsignlanguage.WeuseitinconjunctionwithspokenEnglish.Wechosethisapproachbecauseweneeditwhenoursonisnotwearinghisimplantsorisunabletohearcientlybecauseofbackgroundnoise.Wealsobelievethatitisimportantthathehasaccesstosignlanguageasadeafperson.WehaveadoptedtheapproachadvocatedbyPerierwhosuggestedthatdeafchildrenbegivenaccesstobothoral/auralandsignedlanguagetoenablethemtomaketheirownchoicewhenoldenoughtodoso.Thisstanceseemsentirelyreasonable,maximizingtheopportunitiesavailable.Itwould,therefore,seemreasonabletoencouragethefamilyofadeafchildtosignwiththeirchild.Itisessentialthatthesefamiliesaregiventhesupporttheyneedtodoso,however.Thissupportincludestimeandspacetopsychologicallyadjusttothenewworldinwhichtheyndthemselvesaswellaspracticaland/orWearewellawarethatCIsdonotgiveoursonnormalhearing.Wearealsoawarethatheworksconsiderablyharderthathishearingpeerstoaccesssoundandcommunicatebyusingoral/aurallanguage.Ultimately,hewillhavetochoosewhethertocontinuewithoral/aurallanguage,tousesignlanguage,ortouseacombinationofthe2approaches.Wehavetriedtogivehimthebestfoundationswithwhichtomakethatdecision.CHRISTIANRATHMANN,PHD,ANDGAURAVMATHUR,PHD,COMMENTS:Thereare3strongreasonstolearnbothsignedandwritten/spokenlanguage.First,aspeech-onlyapproachriskslinguisticdeprivationatacrucialperiodofdevelopment.TheriskarisesbecauseofthevariabilityinthespokenlanguagedevelopmentofdeafchildrenwhohaveCIs.Incontrast,bothsignlanguageandearlyreadingarevisuallyaccessibletothedeafchild.Thisbilingualapproachvirtuallyguaranteesthatthechildwilldeveloplinguisticcompetence.Second,bilingualismisbeneBilingualchildrendisplaybetterexibilityandcognitivecontrolaswellasmorecreativethinking,especiallyinproblemsolving.Thesebenetsextendtosocialandacademicsettings.Third,signlanguagedevelopmentcorrelatespositivelywithandspokendevelopment.NoevidencehasbeenfoundthattheuseofavisualMELLONetal at National Institutes of Health Library on June 16, 2015pediatrics.aappublications.orgDownloaded from languageaffectstheoutcomeofcochlearimplantation.Infact,childrenwithCIswithearlyexposuretoand,importantly,continueduseofasignlanguageoutperformchildrenwithonlyCIsonavarietyofstandardizedlanguagemeasuresofEnglish,evenwhenbothgroupshavethesameageofimplantationandthesameyearsofCIuse.Itseemsthatearlyandcontinuedexposuretosignmayprovideaframeworkforearlyspokenlanguageindeafchildrenwithinhearingfamiliesaswellaswithindeaffamilies.TOMHUMPHRIES,PHD,COMMENTS:Themostimportantadviceanyonecangiveparentsofdeafchildrenistoimmediatelyjoinanactivesigningcommunityofbothparentsandchildren.Thisrststepisvitalinachievingthetypeoflanguage,cognitive,andsocialdevelopmentthatdeafchildrenwillneedforFrombirthto3yearsofage,adeafchildneedstobepartofalanguageandcognitiveecosysteminwhichunambiguouslinguisticinputandrichinteractionwithprintpreparethechildforboththeacquisitionofbasicinterpersonalcommunicationskillsandforacademiclanguagedevelopment.Byacquiringsignlanguageearly,thechildcandeveloptheoryofmindandachievetherequisitedomesticationofvision(eg,eyetrackingforreading)tobereadyforschooling.Academiclanguagedevelopmentiswhatweexpectofchildreninschool,thelanguagethatchildrenmustbothaccessanddemonstrateknowledgein.Beingabletocommunicateinsignlanguagewiththeteacherandwithclassroompeersaffordsthedeafchildthesociallyandintellectuallyengagedinteractionthatcomprisessomuchoftheschoolday.Thissocialdevelopmentiscriticaltoabilitytolearnandtotheirmoralandemotionaldevelopment.Asthedeafchildgrows,thefamilyisnotenough,andalargeamountofthestimeisspentawayfromhome.Withsignlanguage,thedeafchildisabletotravelthroughvarioussocialsituationsandcommunitieswithoutcultyandnotbeconnedtocommunicatingonlywithfamilyandfriends,asisoftenthecasefordeafchildrenwhohavenoknowledgeofsignlanguage.DONNAJONAPOLI,PHD,ANDTHERESAHANDLEYCOMMENTS:Alldeafchildrenshouldbetaughtasignlanguageassoonastheirhearingstatusisdetermined,inconjunctionwithtraininginspokenlanguage(foraslongastheyshowprogressandinterest);theirchancesofdevelopingarmlinguisticfoundationarethusmaximized.Simplyput,latelanguagelearnershavearangeofproblems,particularlywithliteracy,whereassigningdeafchildren,withorwithoutaCI,performbetteronliteracyandthosecognitiveskillsthatrequirealanguagefoundation,regardlessofwhethertheirparentsareordeaf.experienceoverallbenetwithnodrawbacksiftheycontinuetosignwhileoraltrainingisstillinprogress.Signandspeechfacilitateeachother,ratherthanonehinderingtheother.misperceptionthatsigninginterfereswithspeechisbasedonwhatsomecallneuropoliticsonthepartofboththemedicalprofessionandthecommunityofparentsofchildrenwithCIs.33,34Inthiscommonscenario,themedicalprofessionputstheburdenofsuccesswithaCInotonthetechnologybutontherehabilitativetrainingthechildreceives,whichamountstoputtingthatburdenprimarilyontheparents.Parents,inturn,tendtobeproudiftheirchildrenmakeprogressandtaketheblameiftheydonot;theseparentsshameeachotherandevenhidefromeachotherthefactthattheysignsometimeswiththeirchildren.Alloftheseactionsaremisguidedbecausetherearenoreliablepredictorsofwhichchildren(amongthosewhoreceivetraining)willsucceedandwhichwillnot.Thefactis,acquiringarmfoundationinasignlanguagegivesthechildthebaseuponwhichtobuildskillsinreadingand,sometimes,speakingasecondlanguage;itisimpossible,however,tolearntoreadwithouthavingarmfoundationinsomeRaisingadeafchildrequiresgreateffortnomatterwhatlanguagechoicetheparentsmake.Raisingadeafchildwithasignlanguageaswellasspokenlanguagerequireslearningasignlanguage.Butraisingadeafchildstrictlyorallyrequiresdailytraininginvocalizationandspeech-readingthroughoutchildhood,whichcertainlydemandsasmucheffortaslearningtosignandcouldstillhavenopositiveeffectsonlanguagedevelopmentbecauseitisimpossibletopredictwhichchildrenwillsucceedwithaCI.Deafinfantsneedexposuretogoodsigningmodels(ie,peopleusingasignlanguagewithallofitsgrammaticalrichness),notjusttogoodspeakers.Variouscombinationsofspeech,gestures,andrudimentarysigningcanhelpinfamilycommunication,andsuchsystemsoftenhavesomestructuralsimilaritiestonaturallanguage.However,thesesystemsarenosubstituteforbonadelanguage,nordotheyallowthechildtocommunicatewithothersoutsidethefamily.Iffamiliespermittheirdeafchildrentointeractwithsigningdeafadults,thesedeafadultswillserveastheresourcethatallowslanguageacquisitiontodevelopnaturally.Deafchildrenalsoneedtointeractwithotherdeafchildrenwhosign.OnecanndtheselanguageandsocialopportunitiesthroughcommunitysupportgroupssuchasPEDIATRICSVolume136,number1,July2015 at National Institutes of Health Library on June 16, 2015pediatrics.aappublications.orgDownloaded from deafadvocacygroups,localdeafandhard-of-hearingcommunitycenters,andlocaland/orstatedeafservicesbureaus.Thefamilycanbeginsignlanguageclassesassoonasthediagnosisofdeafnessisconrmed.Somefamilymembersmaybecomeuentsigners,whileothersmayalwaysfeelawkwardatsigning;thequalityofthefamilyssigningisfarlessimportant,however,thanthefactthatthefamilycommunicateswiththechild.DeafchildrenwhosignwiththeirhearingmothersexhibitearlylanguageexpressivenesssimilartohearingchildrenofthesameagevariabilityinthemothersEvenfamilieswhobecomeexpertsignersneedtobringtheirdeafchildrentoeventswheretheycaninteractwithasigningcommunitybecausetheproperdevelopmentoflanguageinallitscomplexityinvolvesitsusewithinacommunity.Furthermore,therearemanythingsthatdeafadultswhosigntendtodowithdeafchildrenthathearingparentsareunlikelytodowithoutctraining.Deafadultsoftenusechild-directedsigning,inwhichtheireyegaze,methodsofattentiongetting,rateandsizeofsigning,andwaysofmakingbothsignsandobjectsmorevisuallyaccessiblesupportthechildslanguagedevelopment.Deafadultsoftensignonobjects,oronthechildsbody,ormoveobjectsintothechildslineofvision,allspontaneouslyandwithttothechildlanguagelearner.Thisbehaviorallowstheadultandchildtointeractinamoresophisticatedway;deafchildrenofdeafparentsquicklylearntoalternatetheirgazebetweenaparentandabookorobject,thusenhancingcomprehension.Alldeafchildrencouldbenetfromlearningthistechniquebecausesignlanguageskillsareessentialinsuccessfuluseofinterpretersinschool.Furthermore,althoughtherearemanywaysbeingdeaf,thedeafpersonwhogainsapositiveattitudetowardbeingdeafisontheroadtoestablishingahealthyidentity;interactingcomfortablywithotherdeafpeopleviaasignlanguagemaybeastrongaid.JOHND.LANTOS,MD,COMMENTS:Formorethanacentury,physicians,parents,educators,andothershavedebatedhowbesttoraisechildrenwhoaredeaf.NewbornscreeningforhearinglossandthedevelopmentofCIsarethelatesttechnologicaltwistsinthisdebate.However,theydonotalterthefundamentalethicalissue:Childrenneedtolearnlanguage.Theymustlearnitfromparents,teachers,andtheircommunity.Themorelanguagestheylearn,thebetterthesechildrenwillbeabletocommunicate.Allchildrenwouldbebetteroffiftheirparentsallspoke5languagesandtaughtall5totheirchildren;unfortunately,manyparentsdonotspeak5languages.Deafchildrenofhearing(andnonsigning)parentsareuniqueamongallchildrenintheworldinthattheycannoteasilyornaturallylearnthelanguagethattheirparentsspeak.Hearing(andnonsigning)parentsofdeafchildrenareuniqueinthattheyareaskedtolearn,atleastinarudimentaryway,anewandforeignlanguagetocommunicatewiththeirchildren.Someparentseagerlyandwillinglytakeonthischallenge;othersdonotorcannot.Aspediatricians,weneedtokeepup-to-dateonthelatestresearch,translatethatresearchintolanguagethatparentscanunderstand,andhelpthemmakechoicesthatarebestfortheirchild,theirfamily,andthemselves.Therearenoriskstolearningsignlanguagealongwithspokenlanguage,buttherearewell-denedbenets.Forparentsandfamilieswhoarewillingandable,thisapproachseemstobeclearlypreferabletoanapproachthatfocusessolelyonoralcommunication.ACKNOWLEDGMENTSWethankPoornaKushalnager,PhD,oftheRochesterInstituteofTechnology,andScottSmith,MD,MPH,oftheUniversityofRochesterMedicalCenterforconsultingonthisresearchandreviewingdrafts.ABBREVIATIONCI:cochlearimplant1.OlusanyaBO,WirzSL,LuxonLM.Community-basedinfanthearingscreeningforearlydetectionofpermanenthearinglossinLagos,Nigeria:across-sectionalstudy.WorldHealthOrgan.2008;86(12):9562.BradhamT,JonesJ.CochlearimplantcandidacyintheUnitedStates:prevalenceinchildren12monthsto6yearsofage.IntJPediatr.2008;72(7):10233.ChristiansenJB.FifteencochlearimplantJDeafStudDeafEduc.2014;4.MitchellR,KarchmerM.Chasingthemythicaltenpercent:ParentalhearingstatusofdeafandhardofhearingstudentsintheUnitedStates.SignLang.2004;4(2):1385.BruskyAE.Makingdecisionsfordeafchildrenregardingcochlearimplants:thelegalramicationsofrecognizingdeafnessasacultureratherthanadisability.WisLRev.1995:2376.MellonNK,OuelletteM,GreerT,Gates-UlanetP.Achievingdevelopmentalsynchronyinyoungchildrenwithhearingloss.TrendsAmplif.2009;13(4):7.TomblinJB,BarkerBA,HubbsS.DevelopmentalconstraintsonlanguagedevelopmentinchildrenwithcochlearIntJAudiol.2007;46(9):5128.GeersAE,NicholasJG,SedeyAL.Languageskillsofchildrenwithearlycochlearimplantation.EarHear.2003;24(suppl1):46S9.TomaselloM.ConstructingaLanguage:AUsage-BasedTheoryofLanguage.Cambridge,MA:HarvardUniversityPress;2003:21MELLONetal 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10.NiparkoJK,TobeyEA,ThalDJ,etal;CDaCIInvestigativeTeam.Spokenlanguagedevelopmentinchildrenfollowingcochlearimplantation..2010;11.GeersA,SpeharB,SedeyA.Useofspeechbychildrenfromtotalcommunicationprogramswhowearcochlearimplants.AmJSpeechLangPathol.2002;11:5012.ScamblerS.Cochlearimplantsandidentitypolitics:Aparentsperspective.BritishSociologicalAssociationMedsoc.2013Feb;7(1):3442.N/A13.JiangJ,AuerETJr,AlwanA,KeatingPA,BernsteinLE.Similaritystructureinvisualspeechperceptionandopticalphoneticsignals.PerceptPsychophys14.VermeulenAM,vanBonW,SchreuderR,KnoorsH,SnikA.Readingcomprehensionofdeafchildrenwithcochlearimplants.JDeafStudDeaf.2007;12(3):28315.SzagunG,StumperB.Ageorexperience?Theinuenceofageatimplantationandsocialandlinguisticenvironmentonlanguagedevelopmentinchildrenwithcochlearimplants.JSpeechLangHear.2012;55(6):164016.KushalnagarP,MathurG,MorelandCJ,etal.Infantsandchildrenwithhearinglossneedearlylanguageaccess.JClin.2010;21(2):14317.KushalnagarP,HannayHJ,HernandezAE.Bilingualismandattention:astudyofbalancedandunbalancedbilingualdeafusersofAmericansignlanguageandJDeafStudDeafEduc.2010;18.StrongM,PrinzP.AstudyoftherelationshipbetweenAmericansignlanguageandEnglishliteracy.JDeafStudDeafEduc.1997;2(1):3719.PaddenC,RamseyC.Americansignlanguageandreadingabilityindeafchildren.In:ChamberlainC,MorfordJ,MayberryR,eds.LanguageAcquisitionbyEye.Mahwah,NJ:PsychologyPress;20.RinaldiP,CaselliMC,OnofrioD,VolterraV.Languageacquisitionbybilingualdeafpreschoolers:theoretical,methodologicalissuesandempiricaldata.In:MarscharkM,TangG,KnoorsH,BilingualismandBilingualDeaf.Oxford,UnitedKingdom:OxfordUniversityPress;2014:8521.MarscharkM,LeeC-M.Navigatingtwolanguagesintheclassroom.In:MarscharkM,TangG,KnoorsH,eds.andBilingualDeaf.NewYork,NY:OxfordUniversityPress;2014:1522.MarscharkM,HauserPC.HowDeafChildrenLearn:WhatParentsandTeachersNeedtoKnow.OxfordUniversityPress;201123.LynessCR,WollB,CampbellR,CardinV.Howdoesvisuallanguageaffectcrossmodalplasticityandcochlearimplantsuccess?NeurosciBiobehavRev2013;37(10pt2):262124.SeeMarscharkandHauser,note21;quoteisfrompage1525.DavidsonK,Lillo-MartinD,ChenPichlerD.SpokenEnglishlanguagedevelopmentamongnativesigningchildrenwithcochlearimplants.JDeafStudDeafEduc.2014;19(2):–26.SchickB,deVilliersP,deVilliersJ,HoffmeisterR.Languageandtheoryofmind:astudyofdeafchildren.ChildDev27.HutchinsE.Theculturalecosystemofhumancognition.PhilosPsychol.2014;28.MorfordJ.Grammaticaldevelopmentinrst-languagelearners..2003;41(4):68129.RamírezNF,LiebermanAM,MayberryRI.Theinitialstagesofrst-languageacquisitionbeguninadolescence:whenlatelooksearly.JChildLang.2013;40(2):30.HassanzadehS.Outcomesofcochlearimplantationindeafchildrenofdeafparents:comparativestudy.JLaryngol.2012;126(10):98931.GiezenM.SpeechandSignPerceptioninDeafChildrenWithCochlearImplantsAmsterdam,theNetherlands:AmsterdamCenterforLanguageandCommunication;201132.BakerS.VL2IntegrationofResearchandEducation:Brief2:AdvantagesofEarlyVisualLanguage.Washington,DC:NationalScienceFoundationScienceofLearningCenteronVisualLanguageandVisualLearning;201133.MauldinL.Parentsofdeafchildrenwithcochlearimplants:astudyoftechnologyandcommunity.SociolHealthIlln.2012;34.MauldinL.Precariousplasticityneuropolitics,cochlearimplants,andthenitionofdeafness.SciTechnolHumanValues.2014;39:13035.AndrewKN,HoshooleyJ,JoanisseMF.SignlanguageabilityinyoungdeafsignerspredictscomprehensionofwrittensentencesinEnglish.PLoSOne.MathurG,NapoliDJ,PaddenC,etal.Languageoptionsfordeafinfantsandchildren.Availableat:www.optiongrid.org/resources/languageoptions_grid_USA.pdf.AccessedApril20,201537.Goldin-MeadowS,MylanderC.Gesturalcommunicationindeafchildren:noneffectofparentalinputonlanguage.1983;221(4608):38.Goldin-MeadowS,MylanderC,deVilliersJ,BatesE,VolterraV.Gesturalcommunicationindeafchildren:theeffectsandnoneffectsofparentalinputonearlylanguagedevelopment.SocResChildDev.1984;49(339.MayberryRI.Cognitivedevelopmentindeafchildren:Theinterfaceoflanguageandperceptioninneuropsychology.In:SegalowitzSJ,RapinI,eds.HandbookofNeuropsychology.2nded,Vol.8,PartII.Amsterdam,Netherlands:ElsevierScienceB.V.;2002:7140.AkamatsuC,StewartD.Constructingsimultaneouscommunication:thecontributionsofnaturalsignlanguage.JDeafStudDeafEduc.1998;3(4):30241.MaxwellMM.Simultaneouscommunication:thestateoftheart&proposalsforchange.SignLangStud42.KnightP,SwanwickR.WorkingWithDeafChildren:SignBilingualPolicyInto.NewYork,NY:Routledge;2013:43.SpencerPE.Theexpressivecommunicationofhearingmothersanddeafinfants.AmAnnDeaf.1993;138(3):44.ErtingCJ,PreziosoC,OGradyHynesM.Theinteractionalcontentofdeafmother-infantcommunication.In:VolterraV,ErtingC,eds.FromGesturetoLanguagePEDIATRICSVolume136,number1,July2015 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HOWLONGDOESTWOMINUTESLAST?:TheNCAAMensBasketballtournament,otherwiseknownasMarchMadness,recentlyconcluded.Manyofmyfriendscommentedonwhatanexcitingtournamentithadbeenandhowmuchtheyenjoyedwatchingthegames.WhileIenjoycollegeathletics,Idonotenjoywatchingbas-ketballasmuchasothersports.Onereasonisthatthegamesseemtostretchonforsuchalongtime.PerhapsIfeelthiswaybecauseIliketowatchsoccer.Eachhalflasts45minutes,andIhaveaprettygoodideawhenthegamewillend.Thatisnotthecasewithcollegebasketball.AsreportedinTheWallStreetJournal(Life:March24,2015),thelasttwominutesofabasketballgameusuallylastmuchlongerthanthat.Intherst52gamesofthe2015tournament,onaveragethelasttwominutesofthegamestookjustovernineminutestocomplete.Ingamesinwhichtheteamswereseparatedbylessthan10pointswithtwominutestoplay,thelasttwominutestookonaverage10.5minutestocomplete.Amazingly,inonegamethelasttwominuteslasted18.5minutes.Thegamesstretchonforseveralreasons,butchieybecauseofintentionalfoulingandtimeouts.Afoulresultsinastoppageofplayofapproximately50seconds.Ifaplayerfoulsout,coachesaregivenanadditional20secondstomakeasubstitution.Coachescanreservetimeouts.Astherearemanytelevisiontimeoutsduringatournamentgame,coachesmayhaveseveral30secondandevena60secondtimeoutattheirdisposallateinthegame.Inonegame,vetimeoutswerecalledinthelasttwominutes.Threewerecalledwithonlytwosecondsremaininginthegame.So,whileMarchMadnesscanbealotoffun,thewaythelasttwominutesofthegamecanstretchonforsuchalongtimeseemsnotmuchfunatall.NotedbyWVR,MDMELLONetal at National Institutes of Health Library on June 16, 2015pediatrics.aappublications.orgDownloaded from DOI: 10.1542/peds.2014-1632; originally published online June 15, 2015;PediatricsHumphries, Donna Jo Napoli, Theresa Handley, Sasha Scambler and John D. 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