EDUCATION
Teaching American Sign Language to a Normally Hearing Infant with Tracheostenosis A Case Study Susan T. English, B.S.,· Carol A. Prutting, Ph.D.t This remedial program of teaching infants with tracheostenosis to use American Sign Language appears to be a successful procedure for eliciting not only expressive language but also in aiding psychosocial-cognitive development.
TRADITIONALLY, sign language ("sign") has been used in providing a more "natural" language for deaf and severely hearing impaired individuals.f The most directly related research of teaching normally hearing persons to sign is that of teaching apes. Washoe,s a male chimpanzee, was introduced to American Sign Language in which shaping procedures, molding (manipulation of extremities for the desired sign), and expansion of continuous commentary was used by the teacher to teach the signs. Because of the limitations of the ape's vocal mechanisms for production of human speech sounds, signing appeared to be a realistic language modality.
* Department of Speech, University of California, Santa Barbara, Calif. 93106. t Department of Speech, University of California, Santa Barbara. CLINICAL PEDIATRICS
December 1975
In January, 1974, the University of California at Santa Barbara Speech and Hearing Center learned about Adriana from the Public Health Office of Santa Barbara. Her condition at birth was described as a congenitally defective trachea and esophagus, with an emergency tracheotomy necessary because of an abnormal constriction of the trachea (tracheostenosis). Adriana spent the first five and one-half months of her life in Children's Hospital, Los Angeles. She continues at this time to return monthly to the hospital for dilation of the esophagus and replacement of the tracheal tube. Because of the sublaryngeal constriction of the trachea, Adriana is not able to phonate. Adriana's mother reported during the diagnostic evaluation at the University that Adriana requires suction of mucus with a polyethylene catheter as often as once every
1141
ENGLISH AND PRUniNG
FIG. 1. (Above) Mother demonstrating sign for "baby." (Right) Mother molding Adriana to make sign for "baby." (Below) Adriana spontaneously signing "baby."
one-half hour when she suffers from upper respiratory congestion. Further complications were associated feeding problems such as frequent vomiting and diarrhea, commonly found in children with this condition. In cases diagnosed and treated early, the prognosis is extremely favorable; although, over 30 per cent are noted to have associated anomalies. Feeding difficulties such as coughing and gagging and excess salivation are commonly observed." Dr. Theodore Hanley, Director of the University of California Speech and Hearing Center at Santa Barbara, suggested that teaching of sign language to this child might be advisable until such time as voice therapy or surgery could be initiated. The proposed remediation program of teaching manual signs was considered for Adriana to help facilitate speech and language development. At the diagnostic session, Adriana was one year old. She proved to be alert, attentive, and demonstrated imitative abilities. She readily imitated "patty-cake" and raised her right hand to wave "bye-bye." Hearing screening with the Maico MA-24 clinical audiometer in a sound treated
1142
chamber revealed the speech reception sound field threshold to be 20 dB. * This score was perhaps questionable because of her age, but hearing appeared to be normal. According to her mother, Adriana had not produced any vocalizations. She uttered no sounds during the diagnostic session. We recommended to the mother that both she and Adriana be taught sign language in
* Re:
American National Standards Institute, 1969. Vol. 14
No. 12
CLINICAL PEDIATRICS
AMERICAN SIGN LANGUAGE
CHART 1.
The Ontogenesis
of Signs
Age Years Months Weeks
Lexical Item
Stimulus
Response
1.1.2
Milk
Clinician signs and vocalizes stimulus. Picks up milk bottle and signs again. Then, takes A's hand and makes appropriate sign while saying milk.
A. was very receptive to being manipulatedher hand is easily moved into the correct position.
1.1.2
Milk
Mother is instructed to initiate procedure.
Mother correctly executes procedure. After Mother completes routine, A. spontaneously made the sign for milk.
1.1.3
Milk
Clinician holds up milk bottle and signs milk with expiation.
A. looks at the bottle, then at the clinician, smiles and signs milk after delay.
1.1.3
Milk
Clinician signs milk with expiation while sibling holds up milk bottle.
A. imitates.
1.2.2
Milk
Clinician says and signs, "Do you want some milk?"
A. looks at bottle and then signs milk.
1.2.2
Milk
Sibling is asked to get milk bottle from kitchen.
A. signs milk when she sees the bottle, reaches, grasps, and drinks.
1.2.1
Cookie
Clinicial molds A. into making correct sign while saying cookie.
A. reaches for the cookie and puts pan in her mouth while watching clinician.
1.2.1
Cookie
Clinician signs and says cookie.
A. delays, then signs cookie.
1.2.1
Dog
Clinician shows several stuffed toy dogs to A. for the first time. Clinician signs appropriately with expiation.
A. imitates sign.
1.2.1
Dog
Stuffed dogs in view.
A. signs dog without prompting and reaches for dog.
1.2.4
Dog
Sibling brings in toy dog and places it in front of A.
A. picks up dog, places it on her lap and makes appropriate sign on the dog.
1.2.4
Baby
Clinician shows a baby doll to A. for the first time. Clinician signs appropriately with expiation.
A. looks at clinician.
1.2.4
Baby
Clinician says with signing, "Do you want the baby?"
A. reaches for and grasps the baby, holds it in her arms while making the appropriate rocking action for the sign.
Note: A. = Adriana.
order to provide Adriana with a means to formally express language. We explained to her that the program would require total cooperation on her part. She readily agreed. It was arranged that the speech clinician would visit the home for two-hour weekly sessions to be continued indefinitely. American Sign Language was chosen as the sign system since it is the one most commonly used, This system consists of a set of manual gestures and hand shapes which correspond to particular words or concepts; some of the signs are iconic while others are CLINICAL PEDIATRICS
December 1975
entirely arbitrary. Throughout each session, the clinician would pair, simultaneously, a sign with speech whether she was speaking directly to Adriana or to other members of the family present. The procedure for introducing each new sign involved the use of a real object of the chosen word for the week, exaggeration of the appropriate sign, extended verbal expansion, and molding. Adriana's imitations were behaviorally reinforced with verbal praise, pats, and smiles. The mother and siblings present were included in the training sessions and were
1143
ENGLISH AND PRUniNG
encouraged to learn the signs. The oldest sibling, 12 years of age, and the mother were both trained during the initial sessions in how to assist Adriana in making the correct sign, to expand verbally on the sign, and how to reinforce her responses with verbal praise. As Adriana acquired new signs, less and less time was needed to teach each new sign until it was used functionally. Note in Chart I that the time spent on the sign for milk was very much longer than that required for the sign for baby (Fig. 1). Chart I summarizes the acquisition of four signs. American Sign Language was chosen as the sign system since it is the one most commonly used. Adriana was cooperative and could easily be physically manipulated to make the signs. . She responded favorably to praise as demonstrated by her smiling and continued attention to the tasks. Her mother and oldest sibling worked with Adriana throughout the week. The motor complexity of a sign appeared to influence her acquisition. Fouts" reports in training chimpanzees that some signs are apparently easier for a chimpanzee to acquire than others, perhaps because some signs are similar to pre-experimental behaviors in the chimpanzee's repertoire. This was specifically demonstrated when the clinician was demonstrating the sign for "up" (first and second fingers move in an upward direction with palm facing outward) which involves fine motor movements. Adriana appeared to be uninterested in participating either by observing or by imitating the sign. However, when the clinician demonstrated the sign for "dog" which is a gross motor movement (an open hand slaps the thigh of the same side) Adriana immediately imitated the new sign and continued her attention throughout the rest of the session. Early, Adriana displayed receptive understanding when she saw the clinician sign "milk" as demonstrated by her active search-
1144
ing, reaching, and drinking from her milk bottle. Her mother would report that Adriana increased her signing with each new week. Both imitative and spontaneous signing were observed by the clinician and often reported by the mother. The interest and cooperation of all the family members and specifically the mother was undoubtedly of major importance to the success of this learning program. From the beginning, the mother was cooperative, as demonstrated by her ongoing signing to Adriana throughout the weeks of training. On May 29, 1974, she reported that Adriana, age 1.2 years, spontaneously signed frequently every day and that all the family members enjoyed signing with her. Signing allowed Adriana to communicate with other family members. The psychosocial-cognitive development of human beings centers around communication. Until the formalized language of signs was introduced to Adriana, her world consisted of gross motor actions such as flailing about of her arms and legs and facial grimaces. By providing her with functional signs she was able to communicate her basic needs for expression. The current program which parallels normal language development will be continued. If Adriana becomes able to phonate normally it is our clinical prediction that the transition from the manual language mode to the oral speaking mode will occur easily. This prediction is based on the assumption As Adriana acquired new signs, less and less time was needed to teach each new sign until it was used functionally. that oral language is the most natural and easiest mode for communication when the speech and hearing mechanisms are intact. Exact syntactic correlates exist between the two modes. For example, subject-object (mommy sock) and subject-verb (mommy go) structures are signed using the same language structure for two-word utterances. The concept and syntactic forms are the Vol. 14 No. 12
CLINICAL PEDIATRICS
AMERICAN SIGN LANGUAGE
same; however, the modality for communication is different. In other words, Adriana will not have to relearn a new symbol system but should be able to transfer her present system from manual to oral speech. Adriana is presently receiving medical attention every month for dilation of the esophagus and replacement of the tracheal
The interest and cooperation of all the family members and specifically the mother was undoubtedly of major importance to the success of this learning program. tube. Her medical prognosis at this time is uncertain. Over the past six months, her general health condition has improved considerably. Her ability to digest solid foods has improved and upper respiratory infections have decreased. Adriana has demonstrated the ability to operationally use sign language. In the three-month period, she has learned and is
There is a tendency for initiators of foreign-sponsored projects to suggest that their own research teams be invited to Indonesia. This suggestion should not ordinarily be acceded to. As with your own domestically financed projects, in my humble view, you as a great nation should use your own research scholars, who are perfectly adequately qualified. You are fully competent to carry out your own trials and to make your own evaluations. When an outside team makes recommendations, they are often merely appropriate to the social and political organization of the country from which the team members originate. Thus, you can always, and rightly, disregard the recommendations on the basis that they have not arisen from yourselves and are culturally or politically inappropriate.
CLINICAL PEDIATRICS
using eight different signs. Therefore, we feel she is acquiring a foundation of language which will enable her to continue to communicate, through American Sign Language or later, if able, through normal speech.
References 1. Brown, R.: The first sentences of child and chimpanzee. In Studies of Child Language Development, Ferguson, C. A., and Slobin, D. S., Eds. New York, Geld, Rinehart and Winston, Inc., 1973, pp. 445-61. 2. Cicour~l: .A. V., and Boese, R. j.: Sign language acquismon and the teaching of deaf children. In Functions of Language in the Classroom. Cazden, j., and Hymes, Eds. New York, Teachers College Press, 1972, pp. 32-62. 3. Fant, I.: Say It with Hands. Silver Spring, Md., National Association of the Deaf, 1971. 4. Fo.uts, R.: Acquisitio? and testing of gestural signs In four young chimpanzees. Science 180: 978, 1973. 5. Gardner, A. R., and Gardner, B. T.: Teaching sign language to a chimpanzee. Science 1965: 664,' 1969. 6. Silver, H. K., Kempe, C. H., and Bruyn, H. B.: Handbook of Pediatrics, 7th ed. Los Altos, California, Lange Medical Publications, 1967.
Do you invite these teams because you hope that the flattery will make them persuade their governments to give you aid on more favorable terms and in larger amounts? I suspect this is sometimes the case. You would be better without such teams. Sure, invite an individual expert in some precise field; but not a team to assess malnutrition or a team beholden to spread and foster the political and social philosophy of its own government. You must be your own organizational, social, administrative, and political masters. You have the expertise among your own peopleuse them, listen to them, discuss with them, do not let them feel fearful of expressing their views and giving of their knowledge.- Thomas
Pediatric Studies In Developing Countries
Stapleton, Secretary-General of the International Paediatric Association, in Paediatrica Indonesiana,February
1975.
December 1975
1145
Teaching American Sign Language to a Normally Hearing Infant with Tracheostenosis A Case Study Susan T. English, B.S.,· Carol A. Prutting, Ph.D.t This remedial program of teaching infants with tracheostenosis to use American Sign Language appears to be a successful procedure for eliciting not only expressive language but also in aiding psychosocial-cognitive development.
TRADITIONALLY, sign language ("sign") has been used in providing a more "natural" language for deaf and severely hearing impaired individuals.f The most directly related research of teaching normally hearing persons to sign is that of teaching apes. Washoe,s a male chimpanzee, was introduced to American Sign Language in which shaping procedures, molding (manipulation of extremities for the desired sign), and expansion of continuous commentary was used by the teacher to teach the signs. Because of the limitations of the ape's vocal mechanisms for production of human speech sounds, signing appeared to be a realistic language modality.
* Department of Speech, University of California, Santa Barbara, Calif. 93106. t Department of Speech, University of California, Santa Barbara. CLINICAL PEDIATRICS
December 1975
In January, 1974, the University of California at Santa Barbara Speech and Hearing Center learned about Adriana from the Public Health Office of Santa Barbara. Her condition at birth was described as a congenitally defective trachea and esophagus, with an emergency tracheotomy necessary because of an abnormal constriction of the trachea (tracheostenosis). Adriana spent the first five and one-half months of her life in Children's Hospital, Los Angeles. She continues at this time to return monthly to the hospital for dilation of the esophagus and replacement of the tracheal tube. Because of the sublaryngeal constriction of the trachea, Adriana is not able to phonate. Adriana's mother reported during the diagnostic evaluation at the University that Adriana requires suction of mucus with a polyethylene catheter as often as once every
1141
ENGLISH AND PRUniNG
FIG. 1. (Above) Mother demonstrating sign for "baby." (Right) Mother molding Adriana to make sign for "baby." (Below) Adriana spontaneously signing "baby."
one-half hour when she suffers from upper respiratory congestion. Further complications were associated feeding problems such as frequent vomiting and diarrhea, commonly found in children with this condition. In cases diagnosed and treated early, the prognosis is extremely favorable; although, over 30 per cent are noted to have associated anomalies. Feeding difficulties such as coughing and gagging and excess salivation are commonly observed." Dr. Theodore Hanley, Director of the University of California Speech and Hearing Center at Santa Barbara, suggested that teaching of sign language to this child might be advisable until such time as voice therapy or surgery could be initiated. The proposed remediation program of teaching manual signs was considered for Adriana to help facilitate speech and language development. At the diagnostic session, Adriana was one year old. She proved to be alert, attentive, and demonstrated imitative abilities. She readily imitated "patty-cake" and raised her right hand to wave "bye-bye." Hearing screening with the Maico MA-24 clinical audiometer in a sound treated
1142
chamber revealed the speech reception sound field threshold to be 20 dB. * This score was perhaps questionable because of her age, but hearing appeared to be normal. According to her mother, Adriana had not produced any vocalizations. She uttered no sounds during the diagnostic session. We recommended to the mother that both she and Adriana be taught sign language in
* Re:
American National Standards Institute, 1969. Vol. 14
No. 12
CLINICAL PEDIATRICS
AMERICAN SIGN LANGUAGE
CHART 1.
The Ontogenesis
of Signs
Age Years Months Weeks
Lexical Item
Stimulus
Response
1.1.2
Milk
Clinician signs and vocalizes stimulus. Picks up milk bottle and signs again. Then, takes A's hand and makes appropriate sign while saying milk.
A. was very receptive to being manipulatedher hand is easily moved into the correct position.
1.1.2
Milk
Mother is instructed to initiate procedure.
Mother correctly executes procedure. After Mother completes routine, A. spontaneously made the sign for milk.
1.1.3
Milk
Clinician holds up milk bottle and signs milk with expiation.
A. looks at the bottle, then at the clinician, smiles and signs milk after delay.
1.1.3
Milk
Clinician signs milk with expiation while sibling holds up milk bottle.
A. imitates.
1.2.2
Milk
Clinician says and signs, "Do you want some milk?"
A. looks at bottle and then signs milk.
1.2.2
Milk
Sibling is asked to get milk bottle from kitchen.
A. signs milk when she sees the bottle, reaches, grasps, and drinks.
1.2.1
Cookie
Clinicial molds A. into making correct sign while saying cookie.
A. reaches for the cookie and puts pan in her mouth while watching clinician.
1.2.1
Cookie
Clinician signs and says cookie.
A. delays, then signs cookie.
1.2.1
Dog
Clinician shows several stuffed toy dogs to A. for the first time. Clinician signs appropriately with expiation.
A. imitates sign.
1.2.1
Dog
Stuffed dogs in view.
A. signs dog without prompting and reaches for dog.
1.2.4
Dog
Sibling brings in toy dog and places it in front of A.
A. picks up dog, places it on her lap and makes appropriate sign on the dog.
1.2.4
Baby
Clinician shows a baby doll to A. for the first time. Clinician signs appropriately with expiation.
A. looks at clinician.
1.2.4
Baby
Clinician says with signing, "Do you want the baby?"
A. reaches for and grasps the baby, holds it in her arms while making the appropriate rocking action for the sign.
Note: A. = Adriana.
order to provide Adriana with a means to formally express language. We explained to her that the program would require total cooperation on her part. She readily agreed. It was arranged that the speech clinician would visit the home for two-hour weekly sessions to be continued indefinitely. American Sign Language was chosen as the sign system since it is the one most commonly used, This system consists of a set of manual gestures and hand shapes which correspond to particular words or concepts; some of the signs are iconic while others are CLINICAL PEDIATRICS
December 1975
entirely arbitrary. Throughout each session, the clinician would pair, simultaneously, a sign with speech whether she was speaking directly to Adriana or to other members of the family present. The procedure for introducing each new sign involved the use of a real object of the chosen word for the week, exaggeration of the appropriate sign, extended verbal expansion, and molding. Adriana's imitations were behaviorally reinforced with verbal praise, pats, and smiles. The mother and siblings present were included in the training sessions and were
1143
ENGLISH AND PRUniNG
encouraged to learn the signs. The oldest sibling, 12 years of age, and the mother were both trained during the initial sessions in how to assist Adriana in making the correct sign, to expand verbally on the sign, and how to reinforce her responses with verbal praise. As Adriana acquired new signs, less and less time was needed to teach each new sign until it was used functionally. Note in Chart I that the time spent on the sign for milk was very much longer than that required for the sign for baby (Fig. 1). Chart I summarizes the acquisition of four signs. American Sign Language was chosen as the sign system since it is the one most commonly used. Adriana was cooperative and could easily be physically manipulated to make the signs. . She responded favorably to praise as demonstrated by her smiling and continued attention to the tasks. Her mother and oldest sibling worked with Adriana throughout the week. The motor complexity of a sign appeared to influence her acquisition. Fouts" reports in training chimpanzees that some signs are apparently easier for a chimpanzee to acquire than others, perhaps because some signs are similar to pre-experimental behaviors in the chimpanzee's repertoire. This was specifically demonstrated when the clinician was demonstrating the sign for "up" (first and second fingers move in an upward direction with palm facing outward) which involves fine motor movements. Adriana appeared to be uninterested in participating either by observing or by imitating the sign. However, when the clinician demonstrated the sign for "dog" which is a gross motor movement (an open hand slaps the thigh of the same side) Adriana immediately imitated the new sign and continued her attention throughout the rest of the session. Early, Adriana displayed receptive understanding when she saw the clinician sign "milk" as demonstrated by her active search-
1144
ing, reaching, and drinking from her milk bottle. Her mother would report that Adriana increased her signing with each new week. Both imitative and spontaneous signing were observed by the clinician and often reported by the mother. The interest and cooperation of all the family members and specifically the mother was undoubtedly of major importance to the success of this learning program. From the beginning, the mother was cooperative, as demonstrated by her ongoing signing to Adriana throughout the weeks of training. On May 29, 1974, she reported that Adriana, age 1.2 years, spontaneously signed frequently every day and that all the family members enjoyed signing with her. Signing allowed Adriana to communicate with other family members. The psychosocial-cognitive development of human beings centers around communication. Until the formalized language of signs was introduced to Adriana, her world consisted of gross motor actions such as flailing about of her arms and legs and facial grimaces. By providing her with functional signs she was able to communicate her basic needs for expression. The current program which parallels normal language development will be continued. If Adriana becomes able to phonate normally it is our clinical prediction that the transition from the manual language mode to the oral speaking mode will occur easily. This prediction is based on the assumption As Adriana acquired new signs, less and less time was needed to teach each new sign until it was used functionally. that oral language is the most natural and easiest mode for communication when the speech and hearing mechanisms are intact. Exact syntactic correlates exist between the two modes. For example, subject-object (mommy sock) and subject-verb (mommy go) structures are signed using the same language structure for two-word utterances. The concept and syntactic forms are the Vol. 14 No. 12
CLINICAL PEDIATRICS
AMERICAN SIGN LANGUAGE
same; however, the modality for communication is different. In other words, Adriana will not have to relearn a new symbol system but should be able to transfer her present system from manual to oral speech. Adriana is presently receiving medical attention every month for dilation of the esophagus and replacement of the tracheal
The interest and cooperation of all the family members and specifically the mother was undoubtedly of major importance to the success of this learning program. tube. Her medical prognosis at this time is uncertain. Over the past six months, her general health condition has improved considerably. Her ability to digest solid foods has improved and upper respiratory infections have decreased. Adriana has demonstrated the ability to operationally use sign language. In the three-month period, she has learned and is
There is a tendency for initiators of foreign-sponsored projects to suggest that their own research teams be invited to Indonesia. This suggestion should not ordinarily be acceded to. As with your own domestically financed projects, in my humble view, you as a great nation should use your own research scholars, who are perfectly adequately qualified. You are fully competent to carry out your own trials and to make your own evaluations. When an outside team makes recommendations, they are often merely appropriate to the social and political organization of the country from which the team members originate. Thus, you can always, and rightly, disregard the recommendations on the basis that they have not arisen from yourselves and are culturally or politically inappropriate.
CLINICAL PEDIATRICS
using eight different signs. Therefore, we feel she is acquiring a foundation of language which will enable her to continue to communicate, through American Sign Language or later, if able, through normal speech.
References 1. Brown, R.: The first sentences of child and chimpanzee. In Studies of Child Language Development, Ferguson, C. A., and Slobin, D. S., Eds. New York, Geld, Rinehart and Winston, Inc., 1973, pp. 445-61. 2. Cicour~l: .A. V., and Boese, R. j.: Sign language acquismon and the teaching of deaf children. In Functions of Language in the Classroom. Cazden, j., and Hymes, Eds. New York, Teachers College Press, 1972, pp. 32-62. 3. Fant, I.: Say It with Hands. Silver Spring, Md., National Association of the Deaf, 1971. 4. Fo.uts, R.: Acquisitio? and testing of gestural signs In four young chimpanzees. Science 180: 978, 1973. 5. Gardner, A. R., and Gardner, B. T.: Teaching sign language to a chimpanzee. Science 1965: 664,' 1969. 6. Silver, H. K., Kempe, C. H., and Bruyn, H. B.: Handbook of Pediatrics, 7th ed. Los Altos, California, Lange Medical Publications, 1967.
Do you invite these teams because you hope that the flattery will make them persuade their governments to give you aid on more favorable terms and in larger amounts? I suspect this is sometimes the case. You would be better without such teams. Sure, invite an individual expert in some precise field; but not a team to assess malnutrition or a team beholden to spread and foster the political and social philosophy of its own government. You must be your own organizational, social, administrative, and political masters. You have the expertise among your own peopleuse them, listen to them, discuss with them, do not let them feel fearful of expressing their views and giving of their knowledge.- Thomas
Pediatric Studies In Developing Countries
Stapleton, Secretary-General of the International Paediatric Association, in Paediatrica Indonesiana,February
1975.
December 1975
1145
