ROUGH EDITED COPY

EHDI 2019
TOPICAL SESSION 7 - INTERNATIONAL A
TO SIGN OR NOT TO SIGN WITH CHILDREN WITH HEARING LOSS:  WHAT WE BELIEVE AND WHY WE BELIEVE IT
MARCH 5, 2019
3:45 P.M. CST

CART PROVIDED BY:
ALTERNATIVE COMMUNICATION SERVICES, LLC
www.CaptionFamily.com

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This is being provided in a rough-draft format.  Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.  
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	>> All right.  Welcome, everyone thank you for coming at the very, very last bit of your day.  To get started we have one hour and hopefully this is going to be a talk with lively discussion.  But a few disclosures before we get started.  
	No. 1, we don't know sign language.  No. 2, we aren't LSL certified.  Sorry Listening and Spoken Language specialists.  
	We are scientists and clinicians.  And -- but like all humans we have very sometimes strong opinions.  Sometimes we differ from one another.  And we might differ from you.  So those are our disclosures for this talk today.  
	This topic is sometimes controversial.  Because of this, we're really hoping to have a lot of participation.  So to do so I'm hoping everyone can get out their cell phones.  I'm going to wait awkwardly.  And I would like you to text Megan Roberts 02 to this number.  Oh 029 sorry there's a 9 missing.  So Megan Roberts -- sorry.  
	If you're in, it pops up a message that says you're joined something.  
	Did it not work for anybody?  Did it work for somebody?  Raise your hand if it worked for you.  So some people.  Still working.
	>> What was the number again.
	>> MEGAN ROBERTS:  Sorry it's missing a 9.  I'm the worst.  Megan Roberts 029.  Sorry.  Typo.  On the bottom, yes.  
	So if you're just joining us now, Megan Roberts 029 to 37607.  So what this will let us do is when I ask questions, you will type the answer to this number and your answers will anonymously pop up on the screen.  So I'm an introvert.  Are there other introverts in the audience?  Like the thought of raising my hand during a talk gives me hives so I was thinking for the fellow introverts and because this topic can sometimes have differing opinions that this would be a way for us to see all of the opinions but not have that much of the pressure.  I've never done this.  This could be terrible.  But we're in this together.  
	Are we good?  Okay.  
	So let's practice.  
	Does anyone have any tomatoes with them?  I'm worried people are going to throw tomatoes at me.  Anybody have tomatoes.  You're going to type in A if you have a tomato and B if you don't have a tomato and you're going to send it.  
	No tomatoes.  Look at that.  
	Excellent.  
	Okay.  So this is how it's going to work.  
	Sound good?  Okay.  So plan for today.  Do some introductions.  Talk about goals for our field.  Talk about what influences our beliefs, opinions and decisions.  Of course as my husband would say, nerd alert we must go over some data and science.  And then we should brainstorm about some ideas for the future so I'm hoping this is informal and you can be what I call bursty.  So yes of course via text you can participate in the slides.  But at any point in time if you have a burning desire to say something, please, please do so.  I am hoping this is as informal and interactive as possible.  
	So who are we?  I'm a speech pathologist also mother of four tiny humans.  And also a researcher.  My focus is in parent empowerment and how to teach parents how to teach their children to talk that's in the area of autism, hearing loss and language delays so I'm a tiny humans person so Birth to Three parents if you have trouble talking I like to work with the parents to support you in everyday routines and this is -- oh.  So my --
	>> TINA GRIECO-CALUB:  My name is Tina my background is in audiology I'm also a researcher I'm a mother of two.  And I am very interested in understanding how hearing loss influences language and cognitive processes.  
	So although I really like young humans, we tend to look at slightly older humans.  Including preschool and school-age children.  
	>> MEGAN ROBERTS:  So who are you all?  So this is an opportunity for you to with your phone type A through F depending on what you are interestingly you know who I forgot this morning so embarrassed Tina had to tell me I don't have audiologists on the team I was like family, SLPs like where is audiologist.  
	I know, it's so amazing.  I love it when things work out.  Oh, excellent.  Everyone voted?  
	Nice.  Well, thank you guys.  
	So you can kind of see that we have a mix in the audience of providers and family members, which is awesome.  
	So what are some goals for the field?  
	And so in here, I won't show the answers.  So for now you can just type in free text what are some of our goals for the field? 
	These are some amazing goals.  Collaboration.  Access to language.  Shared vision.  Empowerment.  Communication.  
	So you can kind of see that we all share this common vision.  
	I always talk about if I were queen of the world, for me it's that I want every tiny human to be able to share their important message with the world.  And how is the best way we can accomplish that.  
	So how do we accomplish these goals?  Also feel free to use the cell phones to text your response.  
	I'm a big fan of that response.  I think families are key.  When I think about other fields I've worked in, I am so impressed with the field -- this field.  Because from the very beginning, I feel like parents have been more involved than other developmental disabilities from the start.  
	So there's a few others in addition to these, which are about early intervention and parents.  I also think, this is my bias and we'll talk about bias in a minute, I also think we need to do -- we need better science.  And we need science that's not topdown science.  We need science where everybody is at the table, design effective studies where -- because researchers are also biased.  We have our own biases.  And so I would also argue that we need good science that involves community partners from the beginning.  
	Oh having to -- conversations.  -- having difficult conversations.  That is so important.  When I told somebody about this talk they said, oh, the key of the talk is just to make everybody happy.  I was like oh, no, no, my key to this talk is to make everybody uncomfortable because out of discomfort comes flexibility and growth.  
	So I want to unpack all of why we believe what we believe and probably not make anybody happy.  Well, maybe at the very end we can all be happy.  
	So why this talk?  Because we have influence.  As providers, as parents, we have influence over the tiny humans with hearing loss.  We need to reflect about several things.  In my opinion.  To be the most effective in this very important role.  
	We need to understand why we believe what we believe.  
	We need to know what science and research does exist.  And what we might not know yet.  
	And we really need to understand how all of this interacts together so that we can understand how our own biases and our own beliefs might influence how we communicate information to parents, sometimes unintentionally.  
	So now we're getting into the good stuff.  I just don't even know what this is going to say.  
	So in general, what do you believe regarding using sign with children with hearing loss.  And I intentionally was non-specific using the word sign because I do understand that ASL is different than signed supported English and different than other -- let's just keep it broad for now.  Any type of sign.  Even though I know it's different.  What do you believe regarding spoken language development?  So A, B, or C?  So A, negatively impacts.  B, positively.  C, doesn't have any impact on spoken language.  
	Anyone else interested to see these results?  I mean I don't even know.  This is exciting.  This is anonymous the data truly goes to, I don't know, heaven when we're done.  
	Okay.  Everyone reporting their -- duh, duh, duh can I have a drum roll, please.  Anybody?  
	What?  Wow.  
	Really?  Really?  I mean, I also drink the Koolaid.  It's my bias.  
(Chuckles).
	>> MEGAN ROBERTS:  But really?  This is not going to be that fun.  Really?  No As?  No As?  No Cs?  
	Rats.  Maybe they are all in Derrick's talk.  
(Chuckles).
	>> MEGAN ROBERTS:  Okay.  Anyone else shocked by that?  I'm just standing here with my mouth open in front of ya'll.  Okay.  Cool.  
	So how did you make this conclusion?  How did you -- how did you -- why do you believe this?  So what sources of information?  How did you reach this conclusion, also?  Via cell phone.  
	Thank you for those of you who are sharing your thoughts about this.  
	>> (Off microphone) is there any way to read a few of them or shout them out.
	>> MEGAN ROBERTS:  Yes thank you for that feedback I appreciate that I'm finding it super interesting nobody else because they can't read thank you very much.  I'm like this is fascinating, you are like tell me more.  
(Chuckles).
	>> MEGAN ROBERTS:  So personal experience is a big one.  
	Research.  Playing/working with kids.  Research evidence.  Talking to people who have used sign.  So you can kind of see if I were to do a quick thematic analysis that we have some buckets of prior experience and research that is driving these -- the -- this conclusion or these beliefs.  
	I do like the caveat it depends on how it's done.  So there is something to be said that I had this very broad question and didn't at all talk about individual difference.  And so we do -- recognizing you might make different conclusions based on different kids.  
	So I want to talk a little bit about how we make decisions.  You're thinking to yourself, why am I in this talk again?  I thought this was about sign language.  
	So I wanted to just take a step back and unpack a little bit about the fact that we're humans and that we have opinions and we make decisions.  
	And talk about how we have two systems.  One system is fast.  Our fast system it's here and the now it's what we're seeing, it's the experience, it's oak particular it's everyday decisions the problem with the system is it's used quite frequently but more likely to be error prone.  We also have system 2 which is slow, conscious, effortful, that's the deep thinking, kind of the checking to make sure that everything makes sense, it's more complex decision making.  And it's often more reliable.  
	Where this comes into play is in relation to what we call cognitive bias.  And in the area of clinical decision making, they talk about this with physicians.  And it's interesting because there are over 100 biases known biases that affect clinical decision making.  
	If you think of the recommendation to use or not use sign as a clinical decision, it's interesting to think about what are some of the biases that could influence making that recommendation.  
	So it's not surprising then to realize that it's not actually lack of knowledge that lead to a failure in making the right decision but more about problems in the thinking themselves.  It's like you kind of have to have a check of the system.  So how do we overcome biases?  
	So I have a bias.  I am what we would consider a pro signer.  And so I was making this talk.  And I was -- I felt myself like disregarding all of the articles that were against sign like that's a bad journal oh that author, no, no, no, I'm like wait, I'm making a talk about biases and I can feel my own bias taking over the system so I had to stop and say whoa you have to read every article.  You have to read it objectively.  
	Because I could feel myself being pulled in that direction.  Because I had this belief.  
	And so in medicine they have done some work on this.  So you have these type 1 processes which are more hard wired.  My belief, my emotional process, oh I saw that tiny human who did so well.  Overlearned.  I've done it over and over and over again and this helps me make this decision which is a type 1 decision which is often prone to error.  
	So when an -- in order to make the best decision about anything, hopefully you have a bias that's triggered, you recognize the bias, you're motivated to correct it like in my case I was like I can't give this talk and tell them about bias, and be biased.  I was motivated.  I was aware of the direction of my bias, which was pro sign and my debiasing strategy I made myself print out every article regardless of what it said you can evaluate me at the end of the talk and you can -- hopefully I'll be debiased at the end of the talk I'm more likely to present you with information today even with my bias that goes against what I, my own opinion, and your own opinion.  
	But the purpose of us talking about this is hopefully for you to recognize that we all have bias.  Our own biases.  And that perhaps we could, you know, put them in the parking lot for the remainder of the talk.  
	So what are your biases?  
	Great.  I'm pro ASL.  Oh, bias, it could be anything.  So I -- what's one of my other biases.  I'm trying to think of a non-sign bias I'm pro like all parents.  Any time I see not direct therapy -- like direct therapy not working with parents, I don't like any articles.  
	I'm pro -- I have biases related to certain journals.  I'm like very snobby.  Those are some biases.  Uh-huh.  Another one, I think hearing loss treated without implication but also I think signing is important.  
	SLPs don't want anyone to use ASL.  Yeah.  Maybe.  
	ASL is better than Cued Speech.  Yes, no Folgers.  I think that's a good one.  
	I have a humus bias.  I only like one brand of humus.  
	So giving parents choice of a communication.  Right.  So like we have these beliefs.  And sometimes the stronger the belief, the harder it is to change.  
	And so how do our biases impact families?  Because that's ultimately why we decided to do this talk.  So there's been some nice work where people have actually asked parents how they make decisions about the use or not use of sign.  Their communication mode.  So parents have consistently reported the need for unconditional emotional support related to their decision to use sign.  
	I find this very interesting because the reverse was not the case it was not that they needed unconditional emotional support to use spoken language, it was only in one direction, which I found interesting and then they wanted -- they felt like they also needed additional information about learning to use sign.  So in another study, they looked at how -- what influenced parents decision making and they first -- the first finding was that health professionals were one of the key decisions.  Early intervention, you're often in the family's home.  Doctors with their MDs.  I mean parents really value expert opinion.  But they also reported that mode was influenced by the policy of their EI provider so they made statements like early intervention was totally against signing.  I know in my personal work I did a small clinical trial here a few years ago and 75% of families reported that at some time someone told them not to sign with their child.  
	So I know we all believe in family choice, many of us do.  But I also think that sometimes we don't realize our settle behaviors while we're thinking oh it's family choice, we don't really take a step back and reflect upon how we can really influence parents subtly.  
	So maybe we influence them by making statements like this.  Most of my families use sign but the decision is yours.  Right?  
	Or I've seen the greatest gains in children whose parents and teachers don't use sign but the choice is yours.  
	And I wish I were making this up.  But this is what happens.  So we're like oh of course I gave them the choice.  After I told them my bias.  
	So it's important for us to be reflective about our responses.  And knowing our bias, so when a family asks us our opinion, we can really be focused on what they are telling us they need and not our own stuff.  
	So we have learned that biases influence perhaps how we interact with families.  Now we're going to switch in and talk a little bit about how our biases impact how we would research.  
	So I was telling Tina that this is the hardest talk I have ever prepared for in my entire academic career of probably over 100 talks.  Because I was pulling information from all different areas.  So in addition to taking the deep dive in how we make decisions, I also started to look at how hard it is to change someone's opinion.  
	So this -- I don't know if you can read it, it's kind of small.  This article won't change your mind, the facts on why facts alone can't change false beliefs.  As a scientist this makes me want to poke my eyeballs out.  I'm like the facts.  
	But I'll tell you the story of this little kiddo.  This is from autism -- Mark is an autism interventionist and he was 18 months old I watched him get his vaccines and the next day he was spinning in a corner and not talking.  And I watched him.  The day before he had typical language, social.  The next day after the vaccines he was not talking.  
	The science is unequivocal that vaccines do not cause autism.  But that personal experience to me was so striking that when I went to get my own kids vaccinated, which I did, I was like literally had to do so much self-talk because that one moment of seeing that kid was so much more powerful for me than all of the means and all of the standard deviations and all of the P values of all of the studies.  
	And so that's the other bias we have to fight.  We have the tiny humans in front of us that are making gains.  But without experimental control in science we can never be sure of the reasons for those gains.  
	So no matter how strong the evidence, there's very little chance of changing someone's mind unless they want to do it on their own.  
	But there's hope.  The best way to do it is if a group of open-minded people are in a group setting.  That was like the one -- I was like what's the point.  No, I can't ever change peoples' minds?  But it's about being with a group of people where you can feel vulnerable and be open and have real discussions.  
	So moving on to the research side of things, you're wondering why I'm presenting a study perhaps on the use of parachutes.  Has anyone seen this study?  No?  
	Okay.  So they did a randomized clinical trial in which they randomly assigned people to jump out of an airplane with a parachute or to jump out of an airline without a parachute.  
	I don't know who signed up for that study.  
(Chuckles).
	>> MEGAN ROBERTS:  But here is the interesting part.  
	Parachute use did not reduce death or major traumatic injury when jumping from an aircraft in the first randomized evaluation of this intervention.  
	What are you thinking about this?  This is published in the British Medical Journal.  
	So replication, yes.  Yes, WTF I think is absolutely -- yes.  
(Chuckles).
	>> MEGAN ROBERTS:  Yes, please, yes, whoever wrote that.  The plane was not in the air?  Who said that raise your hand, boom.  Yes the plane was 3 feet off the ground.  And why I show you this is because we often take these conclusions this is obviously an exaggerated example but why I'm showing you this is because it's important for us to dig beyond our own biases.  Look at the data.  And look at all of the other factors beyond just what we believe.  
	And so hopefully at this point you're ready to read some research.  Yes?  
	Okay.  
	So before we do that, I want to take a step back and think about -- so when conducting a study, one of the first steps scientists do is they start -- they want to understand -- they have a research question.  In this case, does sign influence spoken language outcome?  But more than just testing that question, oftentimes we want to understand what we call the underlying mechanism so what is driving that relationship between sign and spoken language?  And so let's brainstorm a few reasons why sign might support spoken language development.  
	Sorry; earlier foundation.  Motivation to communicate.  Gestures during the prelinguistic period.  Gestures are part of typical language development.  Stimulates the language center of the brain.  Language foundation.  I absolutely like -- yes, all of these things.  It's a first language.  That's access to a language from birth.  It can bootstrap spoken language development if you think about it as bilingualism one language supporting the second language.  
	So I don't know if this is going to be very interesting since ya'll picked B 100% believe sign support spoken language but let's pretend we have heard some other arguments about why it is not good so what are the reasons that you have heard, even if you don't believe them, that sign might hinder spoken language development?  Incomplete language models.  Using ASL as a crutch.  Parents can't do both.  
	Sign is a crutch.  Not enough vocabulary with sign.  No foundation.  Using baby signs only.  It doesn't.  So we can kind of see -- so there are some other reasons.  One of my favorite is like the dying auditory brain that neuroscientists extraordinaire can go into as I was reading about cat brains it wasn't going very well but before we get into some of the reasons and science behind it I want to talk a little bit about experimental control.  So dust off the cobwebs go back to your research methods class and let's all remember the purpose of science and research study -- good science I should say, is the maintenance of experimental control meaning we want to be sure the changes in dependent variable in the case of spoken language outcomes are only due to the independent variable.  In the case of this talk, mode of communication.  
	So we want to be sure that it is only the mode of communication driving the spoken language outcomes and nothing else.  So keep that in mind as we go through some of these articles.  
	The other thing I wanted to talk about is causation.  And correlation.  
	We have all heard the phrase correlation is not causation so just because things are associated with one another doesn't mean it causes it so you have a sunny day.  Sunny days make the -- associated with ice cream sales sunny days also may be associated with drowning but do we think sunny days cause drowning?  No.  It causes more swimming which results in drowning and do we think sunny days cause homicides probably not sunny days result in more going out and when more people are out there are more homicides.  
	And so this is also important when considering the science because it would be incorrect to assume that ice cream sales causes the murder rate to go up but rather there's this underlying factor, temperature, that's driving both ice cream sales and murder rate.  
	Make sense?  
	Research 101 cobwebs gone.  
	So now we get into the meat of this.  
	So have you guys seen this systematic review, published in pediatrics.  I think one or two years ago.  A group of researchers looked at all studies that examined the relationship between sign language and spoken language in kids with hearing loss.  What a systematic review does is it combs through the literature in a very systematic way.  And looks at all of the studies and tries to make sense of all of the studies together rather than just looking at one study and -- says yes one study says no one study says yes so this tried to integrate all of the literature together.  There were 11 studies and also in addition to looking at the findings they classified or coded each article based on certain methodological or research features.  Sadly were weak four of them moderate study quality and zero strong regardless of what we believe the science in this area is not good it's just not good it's not high quality for many reasons.  So selection bias, who gets into the studies.  
	So are all of the high performing spoken language kids in that group but maybe all of the kids in the sign group have fluent -- have Deaf parents who are fluent signers.  You can imagine how the results of the study change based on who is selected to be in this study.  
	We have study design.  So if you just randomly select existing groups, those groups may differ on something other than communication mode.  
	You might have blinding.  What if the people doing the spoken language outcome know how much sign use and their bias, what if they are like me and they give all of the kids who we know have been exposed to sign we give them more credit on the language measure.  
	There's attrition.  What if a group of kids all drop out of the study that influence the results.  
	So these are all of the reasons why research can be good or bad.  The sad truth, though, is across this body of work the quality of research is not good.  And so that's what they concluded.  That they need more research.  And it's very limited and insufficient high quality evidence.  
	So I'm going to turn this over and talk about one of the first reasons why many people are hesitant to recommend sign, which is reorganization of cortical reasons.  Take it away.  
	>> TINA GRIECO-CALUB:  So I'm here to talk a little bit about the brain and how the brain is organized.  And how that brain organization may change in the face of different sensory input across individuals.  
	So on the -- I usually have a pointer.  I feel naked up here.  So and right-hand side this is sort of -- thank you.  
	Does this work?  Whoa.  
	There we go.  
	Oops.  Okay.  There we go.  
	So on the right-hand side this is normal sensory perception.  And so what these different arrows are suggesting is that when we think about the visual cortex, which is back here in the back of our brain, that the majority of the inputs going into that visual cortex are going to be coming from the visual sensory system.  
	But what these other arrows are showing is that the visual system also represents auditory hearing, somatosensory touch information.  And that is not uncommon.  
	There are many areas of the brain, most all of them with the exception of maybe primary sensory areas that represent multiple sensory information.  
	And so when you have a scenario where an individual loses or does not have access to one of the senses, so in this case, there's vision deprivation, there's no input into that area of the brain from the vision system.  
	And so what ends up happening, because there's plasticity and because the brain wants to be optimized in how it's functioning, other systems will take over.  And the takeover, I'm going to use that phrase actually I don't really like that phrase but I don't have an easier way to say it, essentially allows those other systems to be a little bit overrepresented.  But it provides that person, know, with sort of a higher fidelity sense in the auditory and somatosensory domains which actually is important because that's how they are navigating the world.  
	And so oftentimes this plasticity might be called maladaptive.  I might argue against that.  It's really the brain's ability to change based on the change in its incoming inputs.  
	So I just said that.  So I think the question is do we want to consider that maladaptive or not?  And I think the reason why we want to ask this question is because there are studies out there suggesting that this is maladaptive.  
	That if the visual in the case of someone who doesn't have access to sound because their hearing system isn't delivering sound to that area of the brain that other sensory systems may take over that part of the brain.  And I think that there have been some structural studies.  There have been fMRI studies showing that brains of Deaf individuals look different than brains of hearing individuals.  But I would argue that doesn't necessarily relate to the potential use of using both sign and auditory input and the reason for that is because speech perception involves much more than the auditory cortex.  
	So this is a pretty complex system.  But you can see that in the -- I really like this figure because it kind of shows you the difference between the right hemisphere and left hemisphere so the left hemisphere, which is over here, is -- the hemisphere that we sort of think about in terms of language processing.  And you can see that in both hemispheres, we have these areas of the brain in kind of pink and green which is sort of fundamental auditory processing and that's shared across both of the hemispheres.  But then you can see that there are a lot of other brain structures involved in language processing that's not only unimodal.  It's multi-sensory.  It is a place where there are a number of areas of brain regions that are projecting to it.  
	So when you have such a complex system, it sort of provides an opportunity for multiple sensory systems to come in there and utilize that system.  
	So there have been a number of studies that have looked at the reorganization of cortical regions as Meg said there have been human studies, there have been animal studies.  And we don't have enough time to go through all of these studies.  But the end -- sort of cutting to the chase, there really is no one study -- there's actually no studies that say that the organization or altered organization or reorganization of the brain has a negative influence on -- the inability of the auditory system to utilize auditory input.  So I'm just going to throw these up there you probably can't read them I don't know how much you want to go into them.  
	Yeah.  And the same thing has been -- has been looked at in individuals with cochlear implants.  And if you look in the small print, you often see that the use of sign had no influence on the outcomes.  And so getting back to what Meg had said earlier is that when you're looking at multiple aspects of a child's language development, and there are multiple sources of influence, whether it's SES, age of implantation, duration of implantation use, these factors are all -- often the ones driving the outcomes and sign often has not been shown at least in many of these studies to be an influence in those outcomes.  
	Do you want to say anything else about that?  
	>> MEGAN ROBERTS:  No.  So hopefully Tina has convinced you that despite -- so any time anyone mentions the brain I kind of freak out because I'm not a neuroscientist and I always think anybody who studies the brain must be the smartest person in the world and then I read some of it under her tutelage and just because there's a difference that shows up in the brain doesn't mean there's going to be a significant behavioral outcome so maybe the brains look different but it doesn't mean that the spoken language outcomes are going to be different.  
	So moving a little bit towards -- so that's the brain research.  There's been a bunch of studies that have looked at correlational data whereby there's a bunch of kids in a study.  There's a bunch of variables.  And they look at the relationship, one of which is mode of communication, on spoken language outcomes.  And here are two studies.  And just to give you a sense of the variability one in the first study children who used oral communication did better an speech perception but there was no difference in expressive language and no difference in receptive language and that was kids total communication versus oral communication.  And in the second study they compared kiddoes who had Deaf parents who were fluent signers to Deaf parents fluent signers so everybody had a parent who was Deaf and was fluent in ASL.  
	Some of the kids were Deaf, as well, with cochlear implants.  And some of them were hearing.  And they compared the results of the hearing kids to the cochlear implant kids and found no difference.  
	So that was another example of how you can answer this question in different ways.  
	But that it often depends on who are the kids in this study and what were the methods that they are using.  
	So I often say if I were queen of the world, I would like to know if -- I wouldn't do this because I do believe in parents' choice but if you randomly assigned children to get communication from a fluent ASL user from birth to a group that didn't get it, I would wonder what the results would say.  
	So that would never fly here but apparently they did it in Iran in 2013 and they randomly assigned kids to get auditory visual versus auditory only.  Very small sample.  And they didn't find any difference between the two groups.  
	Another study looked at within the same group of kids who used some level of sign they did a bunch of word learning experiences -- experiments to demonstrate, well, does the processing of visual information and auditory, does that slow down word learning?  And it didn't.  
	So you can kind of see that there is some evidence across a variety of studies that sign language might -- doesn't necessarily rot the auditory brain.  I'm referring to you because you're the audience -- she loves sign language.  To the case of the auditory brain and sign being detrimental so there's some evidence but it's variable and variable being -- and then this study came out.  
	Has anyone read this study?  Yeah, so this would be the study that I would say most people have used as definitive proof that sign language hurts spoken language outcomes.  
	So I'm going to take time to unpack this specific study.  It was 97 kids who were on average implanted around 10 months of age.  They measured exposure to sign before the implant, 12 months later, 24 months later and 36 months later and then they classified kids into groups.  This is not my study.  Short-term exposure in which they -- parents reported exposure to sign language either before the implant or 12 months later.  Long-term exposure which was either before or 12 months after and 24 and 36 months so that's long-term sign exposure.  
	And then parents who reported never using sign was no sign exposure.  So we get the study design?  
	Okay and then they looked at it in relationship to spoken language scores in 5 to 7 years and 9 to 12 years and also reading.  
	And what they found was again dust off the cobwebs we're looking for P values, P values tell us there's a significant difference that's likely not due to chance and we see that so this is short-term versus no sign so in elementary school kids who used short-term sign had poorer spoken language than kids who didn't use sign.  And the long-term group had differences in early and late elementary so the long-term group had poorer outcomes in spoken language than sign in both early and late elementary so reading with similar results only just late elementary and only for the long-term sign versus the no sign group.  
	I mean, right?  It's like all of the numbers.  So what am I looking for also, because science is so interesting.  You can have all of this data but you also have an opportunity to tell the story and if you just look at the words you're kind of taking the beliefs and biases of the authors.  
	So confidence intervals.  Raise your hand if we want a refresher or we got confidence intervals.  We got confidence intervals.  Okay.  So the problem with these confidence intervals are they are large.  So it means -- a confidence interval means that you're 925% confident, this is an ish description for simplicity -- that the true difference is somewhere between 24 points and .4 points.  
	Hmmm . . .
(Chuckles).
	>> MEGAN ROBERTS:  Somewhere in there.  So that's a very big range.  And so that's a lot of variability.  
	So they concluded that sign language exposure is driving poorer spoken language outcomes.  
	But what if a child isn't making progress in language?  And that influences a parent to choose sign.  And so then they get exposed to sign.  And then they have poorer spoken language outcomes.  
	So could it be, in fact, that it might not be the sign exposure but it may be something in the kiddo that is driving the decision to use sign which is then driving sign exposure which is then resulting in the poor language outcomes.  
	Could it be?  Maybe.  We don't know.  
	So what additional data might support or change this conclusion?  So I'll skip that I'll just tell you mine unless you really want to know.  Where we can -- I just want to get to the bottom line and I'm worried about time.  
	So we have these kids.  And they classify them as being exposed to sign at different points in time.  
	And so -- sorry; I'm just going to switch.  
	So over here we have -- imagine this.  Can everyone hear me?  We have this kid.  
	>> (Off microphone).
	>> They are saying they want her to use the microphone.  
	>> MEGAN ROBERTS:  Hello.  Okey-dokey.  
	Okay.  So imagine a kid who before they got implanted their parents decided to sign.  And keep signing.  Sign, sign, sign.  
	That kid has gotten sign the whole time.  And they would be considered long-time sign exposure.  Okay well this kiddo didn't -- his parents didn't sign to him before the implant.  But something made them sign afterwards maybe the kid didn't take -- maybe he just wasn't developing spoken language outcome and they said you know what we need to do something else.  So we're going to do sign, sign, sign.  
	These kids would be classified the same.  
	Even though they are possibly very different kids.  So they are both lumped in this study as long-term sign exposure.  
	And then we have these kiddoes who before implant no exposure to sign.  Then we decided to do sign.  No sign.  Then we decided to do sign so that's inconsistent sign use which would be classified as short-term sign use which may be conceptually different and then we have this kiddo who is -- has had sign here.  But then didn't do sign later maybe because he learned -- was fluent in sign language from the beginning.  Cochlear implant turned on.  Had a symbolic representation was like I got this and the parents were leak, okay, he's using spoken language.  
	These kids would be classified the same.  But you can imagine how they are different.  And you can see where I struggle with this study that we have lumped kids together.  That may have been very different.  Yeah?  So I would kind of want to know -- it would convince me if I could see the language profiles of all of these kids so during this very important time if I could see what was happening with their language skills during this time, I would be more confident that maybe it was actually sign language driving the results.  
	And not some other factor.  
	Are we tracking or is this way too nerdy?  Okay.  Great.  
	Can you click me?  
	>> TINA GRIECO-CALUB:  I got it.  
	>> MEGAN ROBERTS:  So I want to know language scores.  And then I also want to know things like memorable IQ also influences language and then I kind of want to know their rationale for why these authors decided to make these designations for sign users.  
	So then I went on a little scavenger hunt, also known as the rabbit hole.  Circo1 a.m. a few nights ago.  And here is what I found.  
(Chuckles).
	>> MEGAN ROBERTS:  In 2010 the same dataset appeared in JAMA with the same kids in this dataset -- let me refresh this says that sign is terrible, this is the information they provided so gender, income, age, maternal sensitivity, baseline IQ which is the Baily which is a verbal measure.  
	And then auditory perception.  And then they did do speech recognition over at 12, 24 and 36 months they did give speech recognition scores.  
	But in this JAMA paper from 2010 from my rabbit hole of 1 a.m., there was all this data, which you can't easily see.  
	But I'm just going to highlight a few important ones.  
	Huh.  
	They have these expressive and receptive language measures at 12, 24, 36 months after.  Implantation.  I wonder why those weren't included in this paper.  
	They also have a nice measure of non-verbal IQ.  Also interesting it wasn't in this paper.  
	And lastly, there are -- they classified sign language very differently originally.  In the first paper.  
	They classified it as speech only.  Speech with a focus on -- I can't -- speech emphasis.  Sign emphasis.  
(Chuckles).
	>> MEGAN ROBERTS:  So my point is sometimes our biases make us do things to the data to fit a conclusion.  I'm not saying it's the case here.  But I'm saying it's interesting in one paper they define something one way and presented one set of scores.  And then in a different paper, they presented different information and classified sign language in a different way.  
	You're understanding why I asked if you had tomatoes now, right?  I was worried someone would throw them at me.  
	So you might say I don't believe the paper because I see all of the tiny humans on my caseload who make progress with sign.  So it must not be true.  But now hopefully you can say it might not be true because look at all of the methodological issues that are present in the paper.  Yeah?  
	The last thing I will just nerd out on is also the issue of categorizing continuous variables.  
	So the next paper you read, maybe you'll remember this.  
	So they also asked parents to estimate what percentage of sign that they used with their child on a scale of 0 to 100%.  And they just picked the cutoff as 10% or less being no exposure.  
	But what they could have done was they could have gotten -- they could have achieved an estimate of amount of sign exposure that was on a continuous scale so Kid A got 60% sign Kid B got 50% sign and looked at that in relation to spoken language outcomes rather than having these very specific cut points.  
	So is a kid that gets 11% sign that different -- or so% that different than a kid that gets -- 10% that different than 9% so what happens when you cut data like that you increase the risk of a positive result being a false positive but you cut variation because the kids aren't that dissimilar over one step of the line.  
	It also might what we say I know this is so much conceals non-linearity in the relationship.  What this means is it could be -- so linear relationship, sign use increases so sign -- sign use increases, spoken language decrease that would be a -- decreases so that would be a linear relationship it may be that there's not a linear relationship maybe kids that use no sign language have great outcomes.  Kids that are exposed to just a little bit have poorer outcomes.  And then kids that are exposed to a lot of it have good outcomes and that would be like a U.  That could be the case.  But by chopping up the data like this you're not able to look at sometimes it conceals that non-linearity function.  Bottom line categorizing continuous variables, bad, don't do it.  
	Some other methodological considerations is that when we're reading articles to really understand random assignment is the end-all be-all when you randomly assign you get to control for all other factors that are driving things not possible but ideal you want to consider the type of things the timing of it and often the difference between the comparison groups.  
	So in the case of total communication and oral communication, if all the kids in those total communication schools are placed there because they haven't been making progress in a spoken language school, I mean they probably vary on more than just the mode of communication.  
	But wait.  We might know -- we might not know if sign hurts or helps but we do know that auditory verbal approaches work.  They work.  
	So is there clear support -- research supporting the use of auditory verbal therapy for kids with hearing loss.  A, yes.  B, no.  C my brain hurts.  I don't know what to believe anymore.  We're almost done.  Two more slides.  
	All right, duh, duh, duh so also systematic review.  
	So by the Cochrane Collaboration very rigorous and you know what they found?  Not one single study that was rigorous enough to say that auditory verbal therapy worked.  So it's not to say that it doesn't but it sure as heck didn't say it did work so now we're in this situation where there's not exactly clear evidence that sign works but there's not clear evidence that -- I would say there's kind of clear evidence that it doesn't hurt but we don't know if it helps and we don't know if auditory verbal therapy works.  There's just not enough science.  Which as a clinician you're like wait I came to the talk only for you to tell me like I don't -- there's no solution?  Yes, it's terrible.  
	But wait.  (Inaudible) aren't fluent in ASL when a baby is born.  This is an argument that's born so now I'm queen of the world and dreams are free and babies need fluent communication partners.  I would argue that babies need a communication partner I wasn't expecting 100% Bs of just pro sign but imagine a universe in which all babies were able to learn sign language at birth so this is an interesting piece in a Law Journal if you haven't read about it it was really interesting they were arguing about the right to language.  And about the fact that Government should pay for parents to receive education in sign language if they want.  Because often the case is, well, it's not possible.  
	But what if it were possible?  Like what were we were queens and kings of the universe and the Government did give parents a grant to not work for a year and all they do is learn sign language it would be an interesting experiment I bring this up because it was an interesting article about talking about the right to language.  
	So the future.  
	We need more science.  I know.  Until then, we got some studies going on.  More information on our Web sites.  But I have a clinical trial with tiny humans with hearing loss going on.  
	Ei@northwestern.edu for more information going on there and Tina's study her Web site is hll@Northwestern.edu we're trying to help with science base the best we can.  But it's slow.  
	So what are you going to say when a family asks, should I use sign?  Should I not use sign?  Will signing hurt spoken language?  Will signing help spoken language?  So this is where you might not like my answer.  This is where the tomatoes come in.  But you have none.  
	I would like us to say we don't know.  
	And what would you like to do?  And I know that's uncomfortable.  But we actually don't know.  We have beliefs.  We have experiences.  But that is not the same thing as knowing what only science can tell us done by rigorous experiments that have experimental control.  
	So with that, I will thank you for your participation.  I think we have one minute if we have any questions.  But thank you for coming.  And staying here.  
	(Applause).
	>> MEGAN ROBERTS:  Yes, Dan.
	>> So if a parent says --
	>> Wait.
	>> MEGAN ROBERTS:  If a parent says --
	>> Should I use auditory verbal therapy, would the answer be the same?  
	>> MEGAN ROBERTS:  100%.  I mean, my bias was like, hell no.  But yes.  
(Chuckles).
	>> MEGAN ROBERTS:  I was thinking in my head but then I was like shit, no.  
	Yes.  
(Chuckles).
	>> MEGAN ROBERTS:  We don't know.  What would you like to do.  And it's hard because in that moment I was like ew.  But yes, we don't know.  And it's really hard not to know.  
	>> The research about the trial with the babies.  
	>> MEGAN ROBERTS:  E o, my trial with the babies.  Yes.  
	>> Can I take a picture of it.
	>> MEGAN ROBERTS:  Of course.  Yes.
	>> Thanks.  
	>> MEGAN ROBERTS:  Thank you all for coming.  And for experimenting with that cool polling app.  What do you think?  Fun?  Cool.
	>> I loved it.  
	>> There's a lot I can do with that polling app.  

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This is being provided in a rough-draft format.  Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.  
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