Children acquire language without instruction as long as they are regularly and meaningfully engaged with an accessible human language. Today, 80% of children born deaf in the developed world are implanted with cochlear devices that allow some of them access to sound in their early years, which helps them to develop speech. However, because of brain plasticity changes during early childhood, children who have not acquired a first language in the early years might never be completely fluent in any language. If they miss this critical period for exposure to a natural language, their subsequent development of the cognitive activities that rely on a solid first language might be underdeveloped, such as literacy, memory organization, and number manipulation. An alternative to speech-exclusive approaches to language acquisition exists in the use of sign languages such as American Sign Language (ASL), where acquiring a sign language is subject to the same time constraints of spoken language development. Unfortunately, so far, these alternatives are caught up in an "either - or" dilemma, leading to a highly polarized conflict about which system families should choose for their children, with little tolerance for alternatives by either side of the debate and widespread misinformation about the evidence and implications for or against either approach. The success rate with cochlear implants is highly variable. This issue is still debated, and as far as we know, there are no reliable predictors for success with implants. Yet families are often advised not to expose their child to sign language. Here absolute positions based on ideology create pressures for parents that might jeopardize the real developmental needs of deaf children. What we do know is that cochlear implants do not offer accessible language to many deaf children. By the time it is clear that the deaf child is not acquiring spoken language with cochlear devices, it might already be past the critical period, and the child runs the risk of becoming linguistically deprived. Linguistic deprivation constitutes multiple personal harms as well as harms to society (in terms of costs to our medical systems and in loss of potential productive societal participation).

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Every year, 10 000 infants are born in the United States with sensorineural deafness. Deaf children of hearing (and nonsigning) parents are unique among all children in the world in that they cannot easily or naturally learn the language that their parents speak. These parents face tough choices. Should they seek a cochlear implant for their child? If so, should they also learn to sign? As pediatricians, we need to help parents understand the risks and benefits of different approaches to parent–child communication when the child is deaf.

Can skill in a language in a visual modality such as American Sign Language (ASL) contribute to the development of literacy in a spoken language such as English? Are there ways that signing can be used to interact with printed text that helps deaf children make connections to print and consequently, learn to read? What specific practices might users of signed languages engage in to promote an environment for reading development in young deaf children? These are questions very much in the minds of educators, parents, and deaf people themselves. The development of English literacy has been a source of great concern to those with an interest in the education of deaf children. The importance of deaf children learning to at least read and write English in order to participate in the social and economic life of the United States is undisputed. But it is also well accepted that, for whatever reason, a large number of deaf children do not achieve a very high level of reading fluency.The historical focus of ideas about how best to foster the learning of English by deaf children has led to several predominant approaches in classrooms.One focus has been on learning English through speech input via the child's residual hearing or lipreading ability exclusively. Another has been on learning English via visible representations of English in sign, or in other words, creating sign equivalents of English words and, in theory, "signing English". A third theory has been that deaf children can learn English best by reading and writing it. With the primary focus on English input in whatever form above all else, the classrooms of deaf children have been places largely uninformed by knowledge about ASL and the cultural practices of its users. In recent years, there has been much public discussion of how ASL can be "used" to teach English and these ideas have found their way into some classrooms. Although there are a growing number of teachers who are themselves deaf and native users of ASL and teachers who hear but are fluent in ASL, little is known about the specific contexts and types of interactions of their use of ASL in their classrooms.Since a primary goal of schooling for deaf children is the learning of English and the development of reading and writing ability, the juncture between ASL and English in signing deaf children is of particular interest to educators. One reason for the interest in how ASL and English interact is the evidence of good English reading and writing skills among deaf children of ASL signing deaf parents (Chamberlain & Mayberry, 2000;Geers & Schick, 1988;Mayberry, 1989; Padden, 2000). The frequency of the success that deaf children of deaf families have in learning to read and write English suggests the probability that deaf families where ASL is the primary language must be doing something that provides productive access or experience with English text that enables their deaf children to learn to read and write English well. Regardless of whether this thesis is accepted, there is widespread experimentati...