UNIVERSIDAD DE SEVILLA
DEPARTAMENTO DE PSICOLOGÍA EVOLUTIVA Y DE LA EDUCACIÓN
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
Tesis doc o al
Eliana Mas an uono
Memo ia de in es igación p esen ada pa a la ob ención del G ado de
Doc o en Psicología con Mención In e nacional
Se illa, 2018
PhD Candida e
Eliana Mas an uono
Supe iso s
Isabel de los Reyes Rod íguez O iz
Da id Saldaña Sage
UNIVERSIDAD DE SEVILLA
DEPARTAMENTO DE PSICOLOGÍA EVOLUTIVA Y DE LA EDUCACIÓN
Se illa, 2018
Acknowledgemen s
A he end o his amazing scien i ic jou ney he e a e many people o hank, who suppo ed me in
a ious s ages o he hesis.
I am deeply g a e ul o he supe iso s o he hesis, Isabel Rod íguez O iz and Da id Saldaña,
who chose me o his p ojec , pa o he Eu opean LanPe cep ne wo k, and sha ed wi h me ideas
and di icul ies du ing he de elopmen o he p ojec . Thank you, Isabel, o he b illian u o ing,
he con inuous suppo and he e o s in e e y phase o he p ojec .
A would like o acknowledge Gab iella Vigliocco who ga e me he oppo uni y o spend h ee
mon hs as a isi ing s uden a he Depa men o Expe imen al Psychology a Uni e si y College
London, whe e I was in i ed o a end he mee ing o he Language and Cogni ion Lab, sha ing
ideas and hough s wi h he membe s o he Lab ega ding my own p ojec and he p ojec s ealised
in he Lab. I would also like o hank he esea che s a DCAL–Dea ness Cogni ion and Language
Resea ch Cen e–a Uni e si y College London, who ga e me p ecious sugges ions abou my
esea ch.
Fu he mo e, I would like o exp ess my g a i ude o Michele Bu igo who supe ised me du ing a
isi ing pe iod o wo mon hs a he Language and Cogni ion Lab a CITEC, Uni e si y o
Biele eld. Thanks, Michele, o sha ing wi h me you expe ience in da a analysis.

Being my p ojec pa o he LanPe cep ne wo k, he e a e many amazing people ha I egula ly
me ac oss he h ee yea s o he PhD ha inspi ed me, sha ing hei ideas du ing wo kshops and
con e ences. I am especially g a e ul o Mila Vulchano a, he coo dina o o he ITN LanPe cep ,
and o all PIs and esea che s o o he uni e si ies and p i a e sec o s pa ne s in ol ed in he
ne wo k: Valen in Vulchano , Joel Talco , Kenny Co en y, Paul Engelha d , Pia Knoe e le,
Ma hew C ocke , Pablo Gaglia do, Tommy S and all, Rica do Ma os, Te esa Cadie no, Rol
Zwaan, Ka inka Dijks a, Rik Eshuis. Thanks o all ea ly and expe ienced esea che s wi hin he
LanPe cep ne wo k: Alba, La a, Yoana, F iede ike, Ha men, Die ha, Do o a, Sobh, Ioanna, B ian,
Ha m, Shu, Zhihan, and And ea. In pa icula , I would like o hank Ma ina who accompanied me
du ing all s ages o his jou ney.
I would like o hank all colleagues a he Uni e sidad de Se illa who ga e me hei suppo and
iendship du ing his expe ience, Pili, Ellie, Co al, Ma a, Angela, Conchi, Noelia, I ene, Lidia,
So ia. Thanks o all membe s o he Labo a o io de Di e sidad, Cognicion y Lenguaje ha I ha e
no men ioned ye , in pa icula , Joaquin, Ma i, An onio, Ja i, and Ian. I am especially g a e ul o
Co al and Ad ian who helped me wi h sign language and sign-suppo ed speech s imuli eco dings.
This p ojec would no ha e been possible wi hou he coope a ion o he heads o he schools who
g an ing me pe mission o app oach pa en s, sha ing ele an in o ma ion wi h me and acili a ing
es ing o he s uden s. O cou se, I would like o hank o hei coope a ion all s uden s ha ook
pa a his p ojec , hei pa en s, eache s and school p o essionals.
Finally, I would like o acknowledge he Eu opean Union’s Se en h F amewo k P og amme o
esea ch, echnological de elopmen o unding his p ojec [g an ag eemen no 316748].
Eliana Mas an uono
Alla mia amiglia,
a Ricca do
TABLE OF CONTENTS
P e ace. ....................................................................................................................................................... XI
PART 1: INTRODUCTION AND GOALS
Chap e 1
In oduc ion .............................................................................................................................................. 17
1.1 The Educa ion o Dea Child en: Towa ds an Inclusi e Educa ion ...................................................... 17
1.1.2 Dea educa ion in Spain. ........................................................................................................ 20
1.2 Visual Componen s o Language .......................................................................................................... 26
1.2.1 Wha e e wo ks: The o al communica ion philosophy and he signing sys ems. ................ 27
1.2.2 The al e na ing o unes o he o al communica ion app oach and sign-suppo ed speech in
educa ion......................................................................................................................................... 30
1.3 The Speci ici y o Dea P o iles ............................................................................................................ 37
1.3.1 Child en wi h cochlea implan s. ......................................................................................... 39
1.3.2 Na i e sign language use s. ................................................................................................... 47
1.3.3 Dea na i e signe s wi h cochlea implan s. .......................................................................... 52
1.4 Eye acking ........................................................................................................................................... 53
1.4.1 Measu es o eye mo emen s.................................................................................................. 54
1.4.2. Eye- acking in dea s udies. ................................................................................................ 55
Chap e 2
Topic and Goals o his Thesis ......................................................................................................... 59
PART 2: EXPERIMENTAL RESEARCH
Chap e 3
S udy 1: An Eye- acking S udy on he Pe cep ion and Comp ehension o Unimodal and
Bimodal Linguis ic Inpu s by Dea Adolescen s ........................................................................ 67
Abs ac ....................................................................................................................................................... 69

INTRODUCTION
17
Chap e 1
In oduc ion
1.1 The Educa ion o Dea Child en: Towa ds an Inclusi e Educa ion
In ecen yea s, a global shi in educa ional philosophy is leading o he adop ion o a mo e
inclusi e educa ion (Knoo s, Tang, & Ma scha k, 2014). The philosophical pe spec i e unde lying
he phenomenon o inclusion is d i en by he idea o egali a ianism among all lea ne s and he ole
o he ins i u ions o p omo ing in eg a ion (Fe nandez-Viade , 2004; S inson & An ia, 1999).
Inclusion is undamen al o p epa e indi iduals o li e, gi ing he oppo uni y o lea ne s wi h
special educa ional needs o ha e no mal li e expe iences and lea ning om ypical pee s and, a
he same ime, o each and apply democ acy a school by challenging social ejec ion (S inson &
An ia, 1999). This philosophical app oach esul ed in laws, such as he Indi iduals wi h Disabili ies
Educa ion Ac (IDEA), ha egula e he issue o inclusion in he wide ield o special educa ion
(S inson & An ia, 1999). Inclusi e educa ion implies ha all lea ne s should a end egula
class ooms, and eache s, in collabo a ion wi h special educa o s, should adap he s uc u e o he
class oom o acili a e hei lea ning. In ag eemen wi h his cu en ly dominan philosophy, he
educa ion o dea s uden s is also changing di ec ion.
T adi ionally, when en olling hei child en a school, pa en s o dea o ha d o hea ing child en
had wo main op ions (S inson & Klu in, 2014; Tang & Yiu, 2016). The i s op ion, usually
p e e ed o dea child en wi h g ea e access o audi ion, was a mains eam school wi h o al
communica ion p og ams. Gene ally, in public schools, he e a e only one o wo dea s uden s pe
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
18
class oom. In egula class ooms, dea s uden s ecei e consul a ion o addi ional ins uc ion
h ough a eache o he dea , who in many educa ional sys ems is an i ine an eache . This i ine an
eache can only de o e a limi ed ime o each s uden , ha ing o each o many dea s uden s wi h
e y di e se p o iles in a day (S inson & Klu in, 2014). A he bes , s uden s in mains eam
en i onmen s can also bene i o speech language he apy and addi ional se ices a high-school
le el o suppo communica ion access and lea ning, such as no e ake s, in e p e e s, eal- ime
speech- o- ex se ices, migh also be supplied (Schi me , 2001; S inson e al., 1999; S inson &
Fos e , 2000). Mains eam schools a e usually i ed wi h esou ce ooms and sepa a e classes. The
esou ce ooms a e a wo kable op ion o mainly o ally educa ed dea child en. In ac , hey a end
esou ce ooms only o e iewing speci ic subjec s and spend mos o he ime in egula
class ooms. By con as , sepa a e classes a e a less inclusi e op ion, whe e dea s uden s ecei e
hei en i e ins uc ion om a specialised eache o dea educa ion, a ely in e ac ing wi h hea ing
s uden s in egula class ooms.
The second op ion was adi ionally he special school o dea , mainly chosen o child en wi h
lowe o no access o audi ion. In hese special schools, dea child en mainly communica e wi h
each o he using na u al sign languages o any signed sys em, sepa a ely om he spoken language.
Special schools usually p o ide wi h a ange o special se ices, such as psychologis s,
audiologis s, and counsello s, and p opose a wide a ie y o academic, oca ional cou ses and
a hle ic and social p og ams. Recen s udies based on la ge da ase s o he Uni ed S a es e eal ha
s uden s a ending special schools a e mo e likely o use sign language and less likely o use spoken
language han s uden s a ending mains eam ins i u ions (Allen & Ande son, 2010; Sha e ,
Ma scha k, Newman, & Ma de , 2014), and ha e majo con e sa ional di icul ies (Sha e e al.,
2014).
INTRODUCTION
19
In he 21s cen u y, a consequence o he ex ension o he philosophy o in eg a ion, mo e inclusi e
educa ional placemen s ha e become he p e e ed op ion, and 80-90% o dea o ha d-o -hea ing
s uden s now a end mains eam schools (Tang & Yiu, 2016). Ne e heless, a e age dea s uden s
in egula class ooms s ill achie e poo e academic ou comes han hei hea ing pee s (Knoo s &
Ma scha k, 2015; Ma scha k & Hause , 2008). These di icul ies a e e iden e en in child en wi h
cochlea implan s (CIs). Despi e subs an ial e idence ha he use o CIs enhances spoken-language
acquisi ion, and imp o es speech pe cep ion and p oduc ion (Wa son, A chbold, & Nikolopoulos,
2006; Wa son, Ha die, A chbold, & Wheele , 2008), a posi i e impac o cochlea implan a ion on
li e acy is s ill no demons a ed (Ha is, 2016). In eading comp ehension, dea child en ha e he
same di icul ies as hea ing poo comp ehende s (Kyle & Cain, 2015), and s uggle wi h gene a ing
in e ences (Mille , 2002).
Conside ing hese unsa is ac o y ou comes, p ac i ione s in dea educa ion s a ed o e hink an
en i onmen ha could be linguis ically iche and would acili a e communica i e exchanges
be ween dea and hea ing s uden s: models o sign bilingual educa ion we e implemen ed in
mains eam class ooms. These models a e sus ained by esea ch on sign bilingualism (Humph ies
e al., 2012; Ma scha k, Tang, & Knoo s, 2014), which indica e a posi i e e ec o sign language,
oge he wi h spoken language, on he language de elopmen o dea and ha d-o -hea ing child en.
Models o co-en ollmen eaching a e becoming inc easingly popula in many coun ies. Co-
en ollmen eaching di e s om he adi ional mains eam eaching in egula class ooms in how
i p omo es in eg a ion be ween hea ing and dea s uden s. Fi s , in a co-en ollmen se ing i is
necessa y o c ea e a eal communi y o bimodal bilingual use s. To his aim, hea ing s uden s
should necessa ily be in ol ed in p og ams o acqui e sign language. C ucially, wi h he aim o
c ea e an educa ional se ing in which bimodal languages e ec i ely co-exis , a signi ican numbe
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
20
o dea signe s should a end he same class ooms (a leas in a dea -hea ing a io es ima ed a ound
1:3 o 1:4) (Tang & Yiu, 2016). School eache s should engage hemsel es in collabo a ing wi h
he eache s o dea s uden s, eam- eaching wi h hem, and hey a e encou aged o in eg a e
egula educa ion p ac ices wi h hose om special dea educa ion, wi h he aim o b eaking down
ba ie s o lea ning and p omo ing he ac i e pa icipa ion o dea s uden s in he class oom. In a
co-en ollmen class oom much ime need o be de o ed o he o ganisa ion o eaching, as i is
p o ided in wo languages.
G ound-b eaking expe iences o co-en ollmen we e s a ed wi h he TRIPOD p og am in
Cali o nia in 1982. Compa ed o dea s uden s o he same age, he pa icipa ing dea s uden s had
imp o ed ou comes in communica i e in e ac ions, social accep ance and academic skills,
(Ki chne , 2014). Ki chne s essed some aspec s ha ideally a p og am o co-en ollmen should
p omo e: (a) di ec communica ion o dea s uden s wi h hea ing pee s and eache s, wi h no
media ion o in e p e e s o special eache s, b) equal access o an o dina y cu iculum, (c)
in ol emen o dea s uden s in academically challenging asks, and (d) c ea ion o bimodal
bilingual pee g oups in suppo o socio-emo ional s a us.
1.1.1 Dea educa ion in Spain.
A ecen su ey o he Spanish Na ional Heal h Se ice o he popula ion o e 15 yea s old p o ides
in e es ing da a on he Spanish dea popula ion (Gobie no de España, Minis e io de Sanidad,
Se icios Sociales e Igualidad, 2014). Spanish popula ion was classi ied as ollows: hea ing wi h
no di icul ies, hea ing wi h some di icul ies (ha d o hea ing), hea ing wi h many di icul ies, and
no hea ing. A o al o 13 % o he Spanish popula ion (5.041.300 indi iduals) is ha d o hea ing,
o whom 4.3 % (190.900 indi iduals) is aged be ween 15 and 24 yea s. Ano he 3.6 % (1.418.700
indi iduals) hea s wi h many di icul ies, and o hem 0.23% (10.400 indi iduals) is aged be ween
INTRODUCTION
21
15-24 yea s. No indi iduals o he younges ange o age, 15 o 24, a e classi ied wi h no hea ing,
hanks o he use o hea ing aids. In ac , 3.5 % o he Spanish popula ion uses hea ing aids o CIs,
and he majo i y o hem a e aged be ween 15 and 24 yea s (2 %).
Acco ding o da a om he Spanish Depa men o Educa ion, Cul u e and Spo , in he yea 2014-
15, he e we e 7531 dea s uden s in he public educa ional sys em, om p eschool o high school
(4.3% o all s uden s wi h special needs). The majo i y o dea s uden s (a o al o 7024) a e in
public (5388 s uden s) o p i a e (1636) mains eam educa ion, while only 507 dea s uden s a end
special schools o dea (Gobie no de España, Minis e io de Educación, Cul u a y Depo e, 2016).
In Spain, bimodal bilingual educa ion was in oduced o coun e he poo ou comes o dea s uden s
(Valmaseda Balanza egui, 1998). A he end o compulso y educa ion, he pe o mance o dea
adolescen s ma ched he sco es o hea ing pee in hei i s yea s o p ima y school, especially in
eading (Rod íguez-O iz, 2005). These poo educa ional ou comes discou aged he de elopmen
o o al communica ion which in u n impac ed nega i ely on social in eg a ion (Rod íguez-O iz,
2005). This coincided wi h he ad ances in sign language s udies (S okoe, 1960) and he ad an ages
in academic achie emen s o na i e dea signe s compa ed o non-na i e dea signe s ha we e
being epo ed (Meadow, 1980; Musselman, Lindsay, & Wilson, 1988; Wilbu , 1986). The
cogni i e and communica i e bene i s o lea ning sign language in he ea ly yea s was appa en .
These ac o s con ibu ed o he adop ion o bimodal bilingual educa ion. A i s egula ion o
bimodal bilingual educa ion o dea s uden s was app o ed in 1995, wi hin execu i e egula ions
o special educa ion (Real Dec e o 696/95). Wi h espec o dea educa ion, hese ules equi ed
mains eam educa ion o ecognise sign language and p omo e i s use and s udy in schools a ended
by dea o ha d-o -hea ing s uden s. Also, he Real Dec e o equi ed app op ia e sign-language

VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
22
aining o eache s and o he p ac i ione s in ol ed in he educa ion o dea s uden s. Con en s
e e ing o bo h communica i e sys ems, o al communica ion and sign language, became pa o
he s uden s’ cu iculum (A .8, ap.6).
The nex g ea achie emen o Spanish dea indi iduals was he legal ecogni ion o he na ional
Spanish Sign Language (LSE), in 2007 (LEY 27/2007
3
), and, soon a e , o Ca alan Sign Language
(LSC), in 2010 (LEY 17/2010
4
). In 2011 he Cen o de No malización Lingüís ica de la Lengua de
Signos Española (Ins i u e o he Linguis ic No malisa ion o Spanish Sign Language) was
c ea ed, wi h he pu pose o dissemina ing and s anda dising LSE. The same yea , in Andalusia a
law ha egula ed he use o sign language was app o ed (LEY 11/2011
5
).
These laws also egula ed he issue o o al communica ion suppo o dea indi iduals. Schools
had o p o ide a ailable bimodal bilingual educa ional models o dea s uden s, who should be able
o choose hei p e e ed educa ional app oach, o al o signed communica ion. Howe e , in p ac ice
he in e p e a ion o bimodal bilingual educa ion is ex emely uzzy: some schools migh be de ined
as bimodal bilingual, bu use signs minimally (Pé ez Ma in, Valmaseda Balanza egui, & Mo gan,
2014). Bimodal bilingual educa ion ound some limi a ions due o he s uc u e o mains eam
class ooms: dea s uden s, e en in bimodal bilingual p og ams, ypically a ended egula
class ooms wi h a as majo i y o hea ing s uden s and only one o wo dea s uden s. This made
i di icul o ca y ou a bilingual p og am in ol ing eache s and hea ing classma es and did no
help dea indi iduals o ha e a posi i e pe cep ion o bimodal bilingual educa ion. Cabeza-Pe ei o
3
Ley 27 /2007, de 23 de oc ub e, po la que se econocen las lenguas de signos españolas y se
egulan las medias a la comunicación o al de las pe sonas so das, con discapacidad audi i a y so dociegas (BOE, nº
255, de 24 de oc ub e de 2007).
4
Ley 17/2010, de 3 de junio, de la lengua de signos ca alana (BOE, nº 156, de 28 de junio de 2010).
5
Ley 11/2011, de 5 de diciemb e, po la que se egula el uso de la lengua de signos española y los medios de apoyo
a la comunicación o al de las pe sonas so das, con discapacidad audi i a y con so docegue a en Andalucía (BOE, nº
312, de 28 de diciemb e de 2011).
INTRODUCTION
23
and Ramallo (2016) ca ied ou a su ey on 138 dea sign-language use s abou dea educa ion,
among o he opics. Pa icipan s had mo e posi i e opinions o he educa ional sec o han o
cul u e, ou ism, heal hy sys em, anspo s, o access o mul imedia in o ma ion. Howe e , he
younges pa icipan s o he su ey, aged 18 o 35 —who had a ended schools when inclusi e
educa ion was he mo e suppo ed op ion— we e he mos c i ical o he educa ional sys em. The
au ho s sugges ed ha his migh be due o unsuccess ul in eg a ion o dea and hea ing s uden s
in he class oom. Also, as much as 36 % o dea indi iduals we e unawa e o he exis ence o
bilingual schools, and 69% we e dissa is ied wi h he insu icien numbe o in e p e e s o dea
s uden s. Bimodal bilingual in e p e e s, LSE-O al Spanish, a e a key igu e o he success ul
implemen a ion o bilingualism (Rod íguez O iz & Mo a Roche, 2007). Despi e egula ions abou
in e p e ing, including he 2007 law, and he c ea ion o a p o essional deg ee o sign-language
in e p e e s, he dea communi y appea ed o be dissa is ied wi h his se ice.
In addi ion, bimodal bilingual educa ion is a ely applied in i s s ic es o m. A bimodal bilingual
educa ional se ing in ol es he oppo uni y o use and de elop bo h languages, o al and signed.
The p oponen s o he use o pu e na u al languages, o al and signed, a gued ha bimodal bilingual
se ings should no include he simul aneous use o signs and o al language, because hey migh
impo e ish use s’ compe ence in bo h language modali ies (Fe nández & Villa, 2017). The guiding
p inciple o his in e p e a ion o bimodal bilingual educa ion is ha ad anced skills in sign
language a ou cogni i e de elopmen and spoken language in dea child en. In eali y, a ious
o ms o signed communica ion a e usually adop ed in bimodal bilingual se ings o mee he needs
o indi idual dea s uden s.
Co-en ollmen aimed o o e come hese di icul ies o applying bimodal bilingual eaching in
mains eam schools. F om nine ies, co-en ollmen became an op ion o dea s uden s, and schools
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
24
o special dea educa ion also opened o hea ing s uden s (Pé ez Ma in e al., 2014). These
bilingual educa ional se ings a e e no an ini ia i e o he educa ional au ho i ies. I is mo e o a
bo om-up p ocess, which de elops in indi idual schools, eache s, dea communi ies, and amilies
o dea pupils (Mo ales-López, 2008) and is he e o e expanding a a slowe pace.
Fou schools in Mad id a e a i uous example o he passage om being special schools o he
dea o bimodal bilingual cen es wi h co-en ollmen . In 2014, 24% o all school-age dea child en
in Mad id a ended hese schools and mo e han hal o hem (53% o all s uden s) wo e CIs (Pé ez
Ma in e al., 2014). In hese bilingual schools, one ou h o he s uden s in a class oom a e dea
(5-6 dea s uden s and 15-20 hea ing s uden s). The mo e balanced p opo ion o dea and hea ing
s uden s han in he pas makes i possible o p ac ice and ins uc all s uden s in he class oom wi h
bilingual eaching. Bilingual inpu is al eady used a he nu se y and all pupils, dea and hea ing,
sha e he same cu iculum. Class ooms ha e dis inc wo king a eas o ma hema ics, a , LSE,
Spanish, e c. In each a ea, a g oup o dea and hea ing s uden s a e suppo ed in he s udy o he
speci ic subjec , and eaching is adjus ed o hei indi idual le els. Fou addi ional p ac i ione s a e
in ol ed in co-en ollmen in Spain: dea LSE specialis s, co- u o s, speech and language he apis s,
and in e p e e s (Pé ez Ma ín e al., 2014). Dea LSE specialis s, o en quali ied eache s o
educa o s, a e p ima ily equi ed o each LSE o dea and hea ing s uden s, ain amilies and
hea ing eache s in LSE and isual communica ion and p omo e dea cul u al ac i i ies among he
school s a . Two co- u o s, pa icipa ing a he class oom ac i i ies nea ly all he ime, a e
esponsible o acili a ing close collabo a ion in eaching and planning. Speech and language
he apis s, in close collabo a ion wi h co- u o s, p o ide child en wi h audi o y s imula ion o
enhance hei speech de elopmen . Finally, he in e p e e s, who ha e an ac i e ole in he
INTRODUCTION
25
class oom mainly a he le el o seconda y educa ion, gua an ee ha class oom con en s a e ully
con eyed in bo h languages.
P ac i ione s in one o he schools —GAUDEM, in Mad id— also poin o p ojec -based eaching
( abajo po p oyec o) as a ele an cha ac e is ic o co-en olmen a p ac iced he e (Alonso,
Rod íguez, & Echei a, 2009). The pu pose o he p ojec s is he inclusion and he indi idual
de elopmen a eas o weakness, wi h he aim o acqui ing basic knowledge. These p ojec s a e
buil a ound a ne wo k in ol ing he amily, o he class ooms, and e en he en i e school o pai s
o s uden s, no necessa y om he same class oom o equal in age.
Pé ez Ma ín e al. (2014) has e alua ed spoken and sign-language linguis ic skills, and socio-
emo ional de elopmen in child en wi h CIs, aged 0 o 6 yea s, en olled in co-en ollmen p og ams.
Child en we e assessed wi h ch onological- and hea ing-age app op ia e asks. They ound hei
pe o mance was equi alen o ypically de eloping child en o spoken language, audi ion,
ecep i e and exp essi e ocabula y, and ecep i e g amma . Con a y o hea ing child en, dea
pa icipan s sco ed highe in exp essi e han ecep i e ocabula y, con i ming a end al eady
de ec ed in p io esea ch (Gee s, Moog, Biedens ein, B enne , & Hayes, 2009) and a ibu ed o
language eaching s a egies ha emphasize naming. Al hough wi hin no ma i e pe cen ile anges,
ecep i e g amma sco es we e in he lowe anges and highly a iable among pa icipan s e en in
child en wi h CIs and ea ly bilingual skills, hus con i ming i s s a us as one o he mos challenging
linguis ic a ea o dea child en (Inscoe, Odell, A chbold, & Nikolopoulos, 2009). The e alua ion
o LSE skills indica ed ha hese child en had good de elopmen al ajec o ies in bo h
comp ehension and p oduc ion, al hough hey had mainly ecei ed LSE inpu om he school.
Child en also had good socio-emo ional skills. In hei conclusions, Pé ez e al. no ed he g ea
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
32
bilingualism, as o iginally concei ed in special schools o he dea in Eu ope and Uni ed S a ed
in he Se en ies-Eigh ies. They looked a sign language as a undamen al skill o he acquisi ion
o li e acy, o be sha ed by all s uden s and eache s (Ho meis e , 2000), and a co ne s one o he
linguis ic and cul u al he i age o dea communi ies (Padden & Humph ies, 1990). F om he
Nine ies and o e he 2000s, bilingual educa ion slowly sp ead ac oss a ious coun ies. Dea
educa ion became mo e inclusi e, wi h he expansion o co-en olmen eaching expe iences
desc ibed abo e.
While he impo ance o sign languages in dea educa ion was g owing, ex ao dina y ad ances in
hea ing echnology and ea ly in e en ion enewed he discussion abou which educa ional se ing
p o ided dea child en “wi h he bes possible oppo uni ies o educa ional and pe sonal success”
(Knoo s & Ma scha k, 2012, p.2). The a e age age o hea ing loss iden i ica ion has dec eased o
2 mon hs in he Uni ed Kingdom and o 3 mon hs in he Uni ed S a es. Since he beginning o he
2000s, cochlea implan a ion was al eady a ailable in child en 18 mon hs old o e en younge and,
by he mid-Nine ies, indi idually p og ammed digi al hea ing aids we e a ailable in indus ialised
coun ies. The e o e, despi e he ecogni ion o he ele ance o na u al sign language in educa ion
o dea child en, many pa en s o child en wi h CIs p e e ed o en ol hei child en in educa ional
p og ams exclusi ely based on OC.
Be ween he Nine ies and 2000s, addi ional esea ch has ed in o he deba e be ween p oponen s
o OC o child en using CI, and ad oca es o bilingual o TC se ings. I has been sugges ed ha
SSS has he impo an unc ion o suppo ing spoken language in child en wi h CIs wi h bilingual
bimodal skills hanks o he edundan mul ichannel message ha i p o ides (Knoo s & Ma scha k,
2012). Fo example, lexemes un amilia in one linguis ic modali y can be known in he o he .
Howe e , esea ch da a a e inconsis en in suppo ing his idea. On one hand, compa ed o child en

INTRODUCTION
33
wi h CIs in TC p og ams, hose en olled in OC p og ams ha e be e speech pe cep ion (A chbold
e al., 2000; Gee s, B enne , & Da idson, 2003), p oduc ion (Gee s, 2004; Gee s, Nicholas, &
Sedey, 2003; Tobey e al., 2000; Uchanski & Gee s, 2003), and o e all language (Gee s e al.,
2003; Ki k, Miyamo o, Ying, Pe dew, & Zuganelis, 2000; S i sky, Robbins, Ki k, Pisoni, &
Richa d, 2000). Howe e , hese imp o emen s in speech we e usually only ma ginal (A chbold e
al., 2000; Gee s e al., 2003; S i sky e al., 2000). On he o he hand, s udies ha e ound signi ican
ad an ages in ocabula y acquisi ion o ea ly-implan ed child en in TC se ings compa ed o hose
a ending OC p og ams (Conno , Hiebe , A s, & Zwolan, 2000; Yoshinaga-I ano, 2006), which
emphasizes ea ly language s imula ion (Conno e al., 2000). SSS migh ha e a signi ican ole in
he p omo ion o ea ly communica i e exchanges, suppo ing dea child en’s socio-emo ional
g ow h (Yiu & Tang, 2014). SSS ecep i e skills posi i ely p edic ed lea ning in one s udy
(Con e ino, Ma scha k, Sape e, Sa che , & Zupan, 2009), bu in o he s communica i e modes did
no impac lea ning (Robbins, Bolla d, & G een, 1999), wi h dea s uden s lea ning in he
class oom as much om SSS as om o he o ms o communica ion (Cokely, 1990; Ma scha k,
Sape e, Con e ino, Seewagen, & Mal zen, 2004). A ecen sys ema ic e iew o s udies wi h
child en wi h CIs published be ween 1999 and 2013 analysed which communica i e mode be e
p edic ed success ul linguis ic ou comes. The au ho s concluded ha e y limi ed e idence exis s
o de e mine whe he he simul aneous use o signs and spoken wo ds is mo e e ec i e han spoken
language alone o os e o al language (Fi zpa ick e al., 2016).
Di e ences in he ou comes om di e en s udies es ing he e ec i eness o educa ional
app oaches can be due o a ange o ac o s. A limi ed numbe o pa icipan s o como bid
dis u bances no diagnosed ha migh a ec pa icipan s pe o mance a e some. Mo e common
complica ions conce n he lack o s anda dised es s o assessing sign language compe ence (Mann
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
34
& Haug, 2016; Spence , 2016), and inconsis ency in he implemen a ion o TC p og ams (Maye ,
2016), due o he lack o s anda disa ion in he signs used in SSS (Caccamise, Aye s, Finch, &
Mi chell, 1997; Maye , 2016). Dea lea ne s o en ound he o ms o SSS used by he eache s
con using (Johnson e al., 1989). In u n, hey ound SSS ha d (Be ns ein, Maxwell, & Ma hews,
1985), because o he limi ed aining in sign language, especially when TC p og ams we e i s
implemen ed (Powe , 2009). Knoo s and Ma scha k (2012) highligh ed he impo ance o in ensi e
aining in SSS o pa en s and p ac i ione s in ol ed in he educa ion o dea child en; hey mus
acqui e he abili y o con inue o speak luen ly and exp ess seman ic con en wi h concep ually
app op ia e signs.
Mo e impo an ly, mos o his esea ch assessed child en’s language skills ei he in TC/SSS
se ings o in OC se ings, bu a ely wi hin he same g oup o pa icipan s (Giezen, Bake , &
Escude o, 2014), and his mos ly in case s udies (Kla e -Folme , an Hou , Kolen, & Ve hoe en,
2006). The compa ison o OC and SSS me hods wi hin he same g oup o indi iduals wi h CIs
e ealed mo e encou aging and p omising esul s o SSS (Blom & Ma scha k, 2015; Blom,
Ma scha k, & Machme , 2016; Giezen e al., 2014; an Be kel- an Hoo , He mans, Knoo s, &
Ve hoe en, 2016). SSS wi h s uden s wi h CIs has been ound o impac posi i ely he acquisi ion
o new ocabula y (Giezen e al., 2014) e en in lea ning pseudo wo ds o un amilia objec s ( an
Be kel- an Hoo e al., 2016). This was consis en wi h he Dual Coding Theo y (Pai io, 2010;
Pai io, Cla k, & Lambe , 1988), acco ding o which in o ma ion p ocessed by dual channel,
isual-manual and audi o y-o al, c ea es a s onge connec ion in memo y. SSS had posi i e esul s
compa ed o OC also in ansmi ing in o ma ion in class oom con ex s, when ansmi ing complex
con en s (Blom & Ma scha k, 2015) and du ing noisy si ua ions (Blom e al., 2016). CIs a e
INTRODUCTION
35
undoub edly e y e icien in one- o-one in e ac ions, bu less so in noisy con ex s like class ooms
(Ba me e al., 2010).
Impo an ly, he e is no e idence ha sign language o SSS impede spoken language de elopmen
in child en wi h o wi hou CIs (Spence & Ma scha k, 2010). The edundan in o ma ion p o ided
by signs can sus ain spoken in o ma ion, con eying meaning e en when speech is audi o y o
isually ba ely pe cei ed. In his pe spec i e, SSS would no be expec ed o imp o e linguis ic
skills, bu i should simply be used as a de ice o in eg a e and sus ain spoken message. In some
con ex s, child en could g ea ly bene i om using sign language o SSS. Fi s , because be o e
cochlea implan a ion, in he i s mon hs o li e, child en will need he iches linguis ic
en i onmen possible o de elop undamen al linguis ic and cogni i e skills; his will necessa ily
be isual and can be p o ided by sign language. Second, signed communica ion will also be
impo an in he i s pe iod a e implan a ion, as a b idge o communica ion. Thi d, e en when
child en ha e comple ed hei aining in he use o CIs, hey will no always able o p o i ably use
he CIs, o example in noisy con ex s, o simply when equipmen empo a ily mal unc ions occu
o ba e ies a e dead. Finally, SSS will be especially impo an when he child is e y young o
when he s uden is ins uc ed o ca y ou a e y demanding ask (Knoo s & Ma scha k, 2012).
The e is a subs an ial ag eemen in ha ea ly iden i ica ion o hea ing loss and ea ly in e en ion
gua an ee be e ou comes in language and li e acy de elopmen (Spence , 2016). Child en wi h
ea ly implan a ion, who a e mo e likely o de elop be e spoken language han child en i ed wi h
CIs a a la e age, a e usually en olled in OC p og ams. Pa en s o child en who ba ely managed o
de elop language a e cochlea implan a ion migh p e e o en ol hei child en in TC p og ams
(A chbold e al., 2000). This ela ionship be ween he age o implan a ion and he use o OC clea ly
eme ged in a s udy by Hol , S i sky, Neubu ge , and Miyamo o (2004), whe e mos child en
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
36
implan ed be o e 12 mon hs o age (88 %), we e likely o use OC exclusi ely, while only 44.3%
o child en implan ed a he 4 h yea o age did so. Howe e , i has been sugges ed ha all child en,
wi h o wi hou CIs, should ha e an ea ly exposu e o signed communica ion because i can be an
addi ional esou ce in communica ion.
A e an exhaus i e e iew o dea child en de elopmen in dis inc educa ional en i onmen s —
spoken, sign language o sign-suppo ed speech based—, Lede be g, Schick and Spence (2013)
concluded ha he ideal s a egy o enhancing language in dea child en would be o moni o
child en needs a a ious s ages o language de elopmen and adap he mos ui ul app oach o
each speci ic s age and communica i e need. Depending on he lea ne ’s needs, signs, in conce
wi h spoken language inpu , will be used o a g ea e o less ex en , all he way om con eying
only some key lexemes o e en ma king spoken mo phology. Child en wi h a ull ange o op ions
o e ed by isual and audi o y channels bene i om he oppo uni y o shi ac oss di e en
communica i e modali ies, especially when implan ed a an ea ly s age (Tai , De Rae e, &
Nikolopoulos, 2007; Wa son e al., 2006).
In conclusion, we could e hink he ole o TC in e ms o how i helps dea lea ne s o access
in o ma ion. Func ional communica ion, all he way om ini ial pa en -child exchanges, s ongly
a ec s quali y o li e. Fo dea indi iduals, his can be achie ed by using he language modali y —
spoken language, sign language o sign-suppo ed speech— mos app op ia e o each speci ic case
(Kushalnaga e al., 2011). Knoo s and Ma scha k (2012) encou aged hea ing pa en s o child en
wi h CIs o lea n and use sign language on egula basis, especially o suppo ing spoken language.
Child en wi h a iche ea ly linguis ic inpu , signed o o al, a e mo e likely o de elop be e eading
skills (Ha is & Beech, 1998; Lich ens ein, 1998), imp o ed social exchanges, and linguis ic and
academic ou comes, a leas du ing he ea ly yea s (Calde on & G eenbe g, 1997). Dea pa en s
INTRODUCTION
37
mos ly choose bilingual-educa ion op ions o hei dea child en. In con as , hea ing pa en s wi h
dea child en need o ca e ully e alua e he di e en educa ional op ions o hei child en. Fo
hea ing pa en s, a sign bilingual educa ion implies he addi ional e o o lea ning a sign language
and he cul u al alues in ol ed.
1.3 The Speci ici y o Dea P o iles
“Dea child en a e no simply hea ing child en who canno hea ”: he p o oca i e quo a ion om
Ma scha k and Knoo s (2012, p.112) aims o s ess he impo ance o educa ion o bea ing in mind
he di e ences in lea ning and cogni ion be ween dea and hea ing s uden s. P io esea ch had
p o ided e idence o di e ences in academic pe o mance. Dea s uden s lag hei hea ing pee s
in di e en a eas (Ma scha k, Sape e, Con e ino, & Pelz, 2008), including isual-spa ial
p ocessing (Bla o-Vallee, Kelly, Gaus ad, Po e , & Fonzi, 2007; Ma scha k, Mo ison,
Lukomski, Bo gna, & Con e ino, 2013). This is con a y o he common belie ha dea
indi iduals a e mo e skil ul han hea ing pe sons in isual asks. Despi e he eliance on ision o
language, dea lea ne s a e no necessa ily isual lea ne s (Ma scha k e al., 2013). Dea and
hea ing s uden s show a di e en o ganisa ion and use o concep knowledge, and di e en
cogni i e s a egies and expe iences ha can a ec academic ou comes (Ma scha k, 2003).
Iden i ying he ways in which dea o ha d o hea ing s uden s di e om hea ing s uden s is an
essen ial s ep o adjus ins uc ional ma e ials and me hods (Knoo s & Ma scha k, 2015; Ma scha k
& Knoo s, 2012).
Howe e , dea ness e e s o a widely he e ogeneous popula ion which di e s on many dimensions.
Some o he mo e ele an a e ae iology, age o onse o hea ing loss, and he deg ee o he loss. A
hea ing loss can be gene ic o acqui ed and, in he la e case, can ha e p ena al, pe ina al, o
pos na al causes. Language de elopmen is c i ically a ec ed by whe he he onse o dea ness

VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
38
onse is p io o o ollows language acquisi ion (p elingual o pos lingual dea ness, espec i ely)
as well as he deg ee (se e i y) o hea ing loss. A commonly used classi ica ion o hea ing loss
se e i y is p o ided by he In e na ional Bu eau o Audiophonology (BIAP Recommenda ion
02/1, 1996). In a no mal o subno mal hea ing, he a e age one loss is below 20 dB. A mild hea ing
loss, wi h an a e age one loss be ween 21 and 40 dB, causes di icul ies i he oice pe cei ed is
low-pi ched o dis an om he subjec . A mode a e hea ing loss o 1s deg ee, om 41 o 55 dB,
and 2nd deg ee, om 56 o 70 dB, allows o pe cei e speech i he oice is loud. I he hea ing loss
is se e e, o 1s deg ee, om 71 o 80 dB, and 2nd deg ee, om 81 o 90 dB, speech is pe cei ed is
he oice is loud and close o he ea . I he hea ing loss is be ween 91 o 119 dB, ac oss h ee
deg ees o p og essi e se iousness, i is classi ied as e y se e e hea ing loss, also known as
p o ound hea ing loss (Cla k, 1981). Finally, i he a e age one loss is o e 120 dB, he indi idual
su e s o a o al hea ing loss, o cophosis.
Based on he combina ion o hese a iables, he e m dea ness is an umb ella- e m o a g ea
a ie y o cases. The a ie y wi hin dea popula ion is inc eased by he echnology e en ually used
o access audi ion, ei he hea ing aids o CIs, and by he p e e ed language o communica e, ei he
sign o o al language. Resea ch on language and cogni ion in dea ness mainly ocused on
indi iduals se e ely o p o oundly dea ei he wi h CIs o wi h na i e knowledge o sign language.
Resea ch on child en wi h CIs, in pa icula child en wi h ea ly access o audi ion due o ea ly
implan a ion, be o e 12 mon hs o age, add esses he issue o he e ec s o language dep i a ion
e en i only o he i s mon hs a e bi h. On he o he hand, na i e dea signe s, who a e dea
child en bo n om dea pa en s, lea ning sign language as hei na i e i s language, gi e he
possibili y o s udy he impac o dep i a ion o audi ion, bu no language dep i a ion, on cogni i e
and linguis ic ou pu .
INTRODUCTION
39
In he ollowing, esea ch on CI use s and na i e dea signe s will be discussed mo e in-dep h,
highligh ing he espec i e ole in cogni i e and linguis ic de elopmen o dep i a ion o audi ion
and na i e exposu e o sign language. In ac , he associa ion be ween good language skills and
highe -le el cogni i e skills in dea popula ion (Figue as, Edwa ds, & Langdon, 2008; Ho n,
Da is, Pisoni, & Miyamo o, 2005; K onenbe ge , Pisoni, Ha is, e al., 2013; K onenbe ge ,
Colson, Henning, & Pisoni, 2014) can be explained ei he e e ing o he educed pe iod o
audi o y dep i a ion (child en wi h ea ly CIs) o o an ea ly language exposu e (na i e signe s).
1.3.1 Child en wi h cochlea implan s.
A cochlea implan (CI) is an elec onic hea ing p os hesis, su gically implan ed, which eplaces
hai cells o he cochlea wi h elec odes. I is no e y bene icial i dea ness is caused by p oblems
in o he pa s o he hea ing sys em, such as he b ains em, midb ain, o co ical a eas. CIs a e
e ec i e only in child en wi h a p o ound o , occasionally, se e e deg ee o hea ing loss. As in
many o he indus ialised coun ies, in Spain cochlea implan a ion o dea child en became
popula om he beginning o he Nine ies (Juá ez-Sánchez & Mon o , 2010; Man ique & Hua e,
2002). A ha ime, a la ge body o esea ch p o ided e idence o he imp o ed speech pe cep ion
and linguis ic ou comes o child en wi h CIs, compa ed o child en wi h analogous hea ing loss bu
using hea ing aids (Dawson, Blamey, De man, Ba ke , & Cla k, 1995; Tomblin, Spence , Flock,
Tyle , & Gan z, 1999). CIs ha e been demons a ed o be especially e ec i e when ac i a ed a an
ea ly age, be o e wo yea s (Conno , C aig, Raudenbush, Hea ne , & Zwolan, 2006; Hol &
S i sky, 2008; Man ique, Ce e a-Paz, Hua e, & Molina, 2004; Miyamo o, Hous on, Ki k,
Pe dew, & S i sky, 2003; Nikolopoulos, Dya , A chbold, & O’Donoghue, 2004; Tomblin, Ba ke ,
Spence , Zhang, & Gan z, 2005). Ne e heless, i is impo an o bea in mind ha CIs do no
es o e no mal hea ing and do no in ol e apid adap a ion, en ailing uning and con inuous
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
40
adjus men o he pe cep ual p ocesses. The a iabili y in pe o mance o child en wi h CIs is qui e
high. E en when cochlea implan a ion is p o ided ea ly, child en bo n dea ha e necessa ily o
ace he ea lies mon hs o li e wi h no sound, hus hei audi o y expe ience is no equi alen o
ha o hea ing child en. C i ically, dep i a ion o sound a ea ly de elopmen al s ages migh a ec
p ocesses ha a e no di ec ly ela ed o hea ing and audi ion sys ems. De icien pe o mance in
child en, ega dless o CI de ices, migh e lec dys unc ion o mul iple p ocessing sys ems
associa ed wi h dea ness and language delay (Leigh, 2008). The du a ion o dep i a ion o audi ion,
be o e cochlea implan a ion, is also associa ed o delays in socialisa ion and daily li ing skills.
Howe e , he mo o de elopmen does no di ec ly co ela e o he pe iod o dep i a ion o
audi ion, al hough i can be a ec ed by spoken language skills (Ho n e al., 2005).
In he nex sec ions, he b ain c oss-modal eo ganisa ion, he execu i e unc ions and he linguis ic
ou comes in child en wi h CIs a e p esen ed in g ea e de ail.
1.3.1.1 B ain plas ici y.
Resea ch on neu oplas ici y has consis en ly epo ed he impac o senso y dep i a ion in one
modali y on he de elopmen o he emaining modali ies.
Dea indi iduals show inc eased ac ile accu acy (Le änen & Hamdo , 2001) and enhanced isual
a en ion, p ima ily in he pe iphe ally isual ield (Ba elie e al., 2000; Dye & Ba elie , 2013;
P oksch & Ba elie , 2002). S udies on b ain plas ici y indica e ha p ima y senso y a eas, which
no mally would se e o p ocess in o ma ion om he dep i ed audi o y modali y, a e in ol ed in
c oss-modal compensa o y adap a ion, p ocessing in o ma ion om he emaining modali ies.
Thus, audi o y a eas a e ac i e du ing isual and soma osenso y p ocessing in dea indi iduals
(Aue , Be ns ein, Sungka a , & Singh, 2007; Finney, Fine, & Dobkins, 2001).
INTRODUCTION
41
Child en wi h CIs o e a unique iew om a neu ode elopmen al pe spec i e o obse e b ain and
neu al eo ganisa ion a e a pe iod o audi o y dep i a ion and, consequen ly language delay
(Pisoni e al., 2008). The mo e e ec i e and ex ensi e c oss-modal plas ici y is, he less senso y
implan s —aimed o es o e he idle senso y modali y— a e likely o be success ul. Thus, he
e ec i eness o CIs migh be hinde ed by c oss-modal eo ganiza ion be o e implan a ion, ha
implies a isual ‘ akeo e ’ o he audi o y modali y and could comp omise he abili y o audi o y
co ex o p ocess spoken language a e he ac i a ion o CIs (K al & Sha ma, 2012; Lyness, Woll,
Campbell, & Ca din, 2013). Campbell, Macsweeney, and Woll (2014), ocusing on p o ound
p elingual dea child en who ne e ecei ed acous ic inpu be o e cochlea implan a ion, a gued
ha he exposu e o non-audi o y signals be o e implan a ion dis o s he unc ion o he audi o y
co ex, nega i ely impac ing on CIs e ec s and speech ou comes. The e a e c i ical pe iods o he
phases o senso y de elopmen , and expe ience can signi ican ly modi y human beha iou and
ela ed aspec s o b ain unc ioning du ing his sensi i e pe iod. C oss-modal eo ganisa ion in dea
child en implies a isual akeo e o he audi o y modali y, limi ing he bene i s om he
ampli ica ion p o ided by CIs (K al & Sha ma, 2012). Fo his eason, sign language exposu e in
he sensi i e pe iod o language acquisi ion has been conside ed a isk o he p ese a ion o he
po en ial o he audi o y co ex o p ocess audi o y inpu in u u e a e cochlea implan a ion
(Gi aud & Lee, 2007). E en o ms o isual language associa ed o spoken language, such as
speech eading, i used be o e cochlea implan a ion, could ha e an impac on c ossmodal plas ici y,
and hinde he unc ioning o he audi o y modali y in a ou o he compensa o y changes in he
isual modali y (Hi ano e al., 2000). In some implan a ion p og ams, aining o he audi o y
modali y is s ongly p omo ed o he expense o isual suppo , and sign language, speech eading,
o cued speech a e banned om he language aining o dea child en p io o implan a ion (Chan,
Chan, Kwo k, & Yu, 2000; Ing alson & Wong, 2013; Yoshida, Kanda, & Miyamo o, 2008).
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
48
1.3.2.1 B ain plas ici y.
Congeni ally dea na i e signe s a e an in e es ing popula ion o s udying neu al plas ici y. This
is because changes in he b ain neu oana omy can be connec ed o bo h cogni i e ac o s — ela ed
o he lea ning o a signed language, o example—, and ac o s ela ed o senso y dep i a ion.
Cogni i e ac o and senso y dep i a ion would a ec dis inc subs a es ana omically and
unc ionally. Sign language lea ning causes plas ic changes in he le supe io empo al co ex,
while audi o y dep i a ion causes plas ic e ec s in he igh supe io empo al co ex, as eme ged
by compa ing p o ound dea na i e signe s o o ally educa ed p o ound dea non-signe s (Ca din
e al., 2013). Func ional neu oimaging s udies p o ide e idence o an addi ional ac i a ion o he
le pa ie al lobe du ing sign language p ocessing ha i is no de ec ed in spoken language
p ocessing (Emmo ey, Meh a, & G abowski, 2007; MacSweeney, Capek, Campbell, & Woll,
2008). This di e ence is epo ed o signe s, bo h dea and hea ing, compa ed o non-signe s, and
consequen ly has been a ibu ed o sign language expe ise (Allen, Emmo ey, B uss, & Damasio,
2008).
A ecen MRI s udy, compa ing p o oundly congeni ally and gene ically dea pe sons wi h na i e
Ame ica Sign Language o hea ing indi iduals, de ec ed a ne wo k o b ain a eas wi h an enhanced
esponsi eness o pe iphe al isual s imuli in dea indi iduals. In pa icula , highe esponsi eness
o pe iphe al a he han pe i o eal isual s imuli was e iden in he Heschl’s gy us egions, we e
human p ima y audi o y co ex is loca ed, highligh ing a unc ional connec ion be ween he
p ima y audi o y co ex and he c oss-modal compensa o y p ocessing (Sco , Ka ns, Dow,
S e ens, & Ne ille, 2014).

INTRODUCTION
49
1.3.2.2 Visual cogni ion in dea na i e signe s.
Wi h ega ds o isual cogni ion in dea na i e signe s, Ba elie , Dye, and Hause (2006) poin ed
ou ha changes ollowing congeni al dea ness a e highly speci ic. No di e ences be ween dea
and hea ing indi iduals ha e been ound in senso y measu es, such as b igh ness disc imina ion,
isual licke , aspec s o con as sensi i i y, o di ec ion and eloci y o mo ion (Boswo h &
Dobkins, 1999, 2002; B ozinsky & Ba elie , 2004; Finney e al., 2001). Dea na i e signe s ha e
been ound o ha e be e isual-spa ial skills han hea ing indi iduals in some domains, bu no in
o he s. S udies on isual a en ion, con olling o con ounding a iables such as language luency
and ae iology o hea ing loss, show enhanced isual cogni ion in dea na i e signe s wi h espec
o hea ing indi iduals, wi h as e shi s o isual a en ion (Re enbach, Dille , & Si e eanu, 1999)
and inc eased pe iphe al isual a en ion (P oksch & Ba elie , 2002). Dea na i e signe s and
hea ing con ols pe o med di e en ly especially when isual s imuli, pe iphe al loca ed o in
mo ion, equi ed a en ional selec ion (Ne ille & Lawson, 1987a; Ne ille & Lawson, 1987b). In
ac , s udies on a en ional o ien ing and execu i e a en ion, do no ind di e ences be ween dea
and hea ing pa icipan s in he p ocessing o cen al s imuli. Di e ences we e ound when
expe imen al asks opposed cen al and pe iphe al s imuli o each o he . In he well-known se ies
o s udies by P oksch and Ba elie (2002), using he use ul ield o iew (UFOV) pa adigm, dea
and hea ing pa icipan s we e equi ed o iden i y a shape appea ing in he cen al egion, a ound
he locus o ixa ion. Reac ions imes e ealed ha na i e dea signe s we e longe in p ocessing
he ials wi h dis ac o s in he pe iphe y and as e when he dis ac o s appea ed in he cen al
egion o ixa ion, con a ily o hea ing pa icipan s. Howe e , when pa icipan s we e in ol ed in
a pe iphe al ask and we e asked o igno e cen al dis ac o s, hea ing indi iduals we e mo e
dis ac ed han dea indi iduals. Taken oge he hese indings sugges ha he dis ac ion e ec
does no p o ide e idence o a de iciency in isual a en ion in dea indi iduals, a he i indica es
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
50
he eme gency o a compensa o y mechanism ha esul s in a di e en dis ibu ion o a en ional
esou ces ac oss he isual ield in dea and hea ing indi iduals (Ba elie e al., 2006).
1.3.2.3. Execu i e unc ioning in dea na i e signe s.
While na i e and non-na i e signe s ha e in common he ini ial dep i a ion o audi ion, hey do
no ha e equi alen expe iences o ea ly linguis ic inpu . In ac , na i e signe s a e exposed om
bi h o he sign language o hei pa en s and amily. A ound 50% o dea child en o hea ing
amilies who quali y o a CIs e ec i ely unde go implan a ion, unlike child en o dea pa en s,
who a e y a ely implan ed (Hall, Eigs i, Bo eld, & Lillo-Ma in, 2017b). Exposu e o language
du ing he p ena al pe iod and he i s mon hs o li e, seems o be de e minan o he de elopmen
o child language and cogni i e unc ioning. Na i e signe s a e exposed o signs immedia ely a e
bi h, ini ially by ouch and soon a e , also isually (Knoo s, 2016).
As consequence, he s udy o dea na i e signe s allows us o explo e he link be ween language
skills and execu i e unc ions, con olling o he amoun o audi o y dep i a ion. Di e ences
be ween dea child en wi h and wi hou na i e sign language a e unde s ood o be he esul o an
in eg a ed sys em ha includes he audi o y sys em and he cogni i e unc ions, p ima ily execu i e
unc ions.
Resea ch in his a ea indica es ha ea ly exposu e o a language has a s ong impac on he
de elopmen o execu i e unc ions, and o he cogni i e and beha iou al unc ions. Dea na i e
signe s pe o med simila ly o hea ing child en wi h espec o heo y o mind (Cou in, 2000;
Schick, de Villie s, de Villie s, & Ho meis e , 2007), IQ (B aden, 1987) o sus ained a en ion
(Dye & Hause , 2014). In Hall e al. (2017b), dea na i e signe s we e epo ed o ha e age- ypical
INTRODUCTION
51
execu i e unc ions on he BRIEF ques ionnai e, al hough wi h sligh ly lowe sco es in wo king
memo y and inhibi ion han a hea ing age-equi alen con ol g oup.
Wi hin execu i e unc ions, wo king memo y has been ex ensi ely s udied. While dea child en
wi h no na i e sign language ha e, on a e age, sho e wo king memo y spans in di e en asks
(Pisoni e al. 2008), na i e signe s ha e a compa able wo king memo y o hea ing indi iduals
(Bou la, Supalla, Newpo , & Ba elie , 2004), and, e en a supe io isual-spa ial memo y han
indi iduals wi h no sign languages (Hall & Ba elie , 2010). Ma shall e al. (2015) ound ha dea
child en who expe ienced a pe iod o language dep i a ion sco ed wo se han hea ing child en,
while dea na i e-signing child en had a memo y pe o mance compa able o ha o hea ing
con ols.
The di e ences in wo king memo y asks could descend om language-based execu i e
unc ioning (Ma scha k, Spence , e al., 2015; Pisoni e al., 2010). Dea indi iduals, ega dless o
hei p e e ed language modali y, ha e been ound o pe o m simila ly o hea ing indi iduals in
isual-spa ial memo y asks which do no allow easy labelling o e bal-sequen ial coding. Dea
na i e signe s e en ou pe o med hea ing pee s in isual-spa ial memo y asks, such as he Co si
Blocks ask (Wilson, Be ge , Niculae, & Klima, 1997) and showed longe backwa d memo y span
han hea ing con ols —who a e usually ound o ha e longe o wa d han backwa d memo y span
(Wilson e al., 1997). The compa able o wa d and backwa d spans in dea na i e signe s could be
explained h ough hei use o isual spa ial coding, such as isual image y, in sequen ial memo y
asks (Hall & Ba elie , 2010). On he con a y, non-na i e dea signe s had majo di icul ies
(Alama go , Lambe , Thebaul , & Dansac, 2007; Ma scha k e al., 2013).
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
52
Bu ecen indings sugges ha pe o mance on isual-spa ial wo king memo y asks migh be
mo e ela ed o he p o iciency in a language —spoken o signed—, a he han o he na i e
knowledge o sign language (Ma scha k, Spence , e al., 2015). The pe o mance in isual-spa ial
wo king memo y asks, compa able in dea and hea ing indi iduals when no in ol ing linguis ic
decoding, appea s o be independen no only om sign language skills, bu also om he hea ing
s a us, which is i ele an whe he pa icipan s wea CIs (López-C espo, Daza, & Méndez-López,
2012; Ma scha k, Sa che , & T ani, 2016). These esul s migh ha e impo an pedagogical
implica ions. In ac , dea educa ion, especially o na i e signe s, o en eso s o he use o isual
ma e ial and me hods, based on he assump ion ha na i e signe s would be isual lea ne s
(Hause , Lukomski, & Hillman, 2008; Ma scha k & Hause , 2012). I isual-spa ial wo king
memo y is no be e in dea han in hea ing s uden s, he ad an ages o isually o ien ed eaching
me hods could be called in o ques ion.
1.3.3 Dea na i e signe s wi h cochlea implan s.
Bimodal bilingual dea child en who a e na i e signe s and who unde wen cochlea implan a ion
a e e en ewe han non-implan ed dea na i e signe s. Only ecen ly he a i ude owa d cochlea
implan wi hin dea communi ies is becoming mo e posi i e (Paludne iciene & Leigh, 2011).
Encou aging ou comes o dea na i e signe s wi h CIs e ealed ha hese child en we e able o
pe o m simila ly o bimodal bilingual hea ing con ols wi h na i e sign language, in a ull ange
o linguis ic measu es which include ocabula y, a icula ion, syn ax, gene al language skills, and
phonological awa eness (Da idson, Lillo-Ma in, & Pichle , 2014). Dea na i e signe s wi h CIs
achie ed highe spoken language sco es han hose p edic ed o monolingual CI use s (Nicholas
& Gee s, 2008). A longi udinal s udy on he e bal acquisi ion o a dea child wi h CIs and wi h
dea signing pa en s highligh ed he posi i e impac o ea ly exposu e o sign language on he
INTRODUCTION
53
cons uc ion o concep ual ep esen a ions and spoken language, which eached le els o his
hea ing pee s (Rinaldi & Caselli, 2014).
Neu oimaging echniques, oge he wi h s anda dized es ing and expe imen al beha iou al
esea ch, ha e been ex ensi ely used o explain linguis ic ou comes and p ocessing in dea
child en, bo h wi h CIs and wi h na i e sign language. Recen ly, esea ch on dea cogni ion has
inc easingly also inco po a ed eye- acking echnology, use ul o he obse a ion o isual
beha iou in ela ion o he pe cep ion o linguis ic inpu s.
1.4 Eye acking
Eye acking is a s a e-o - he-a esea ch ool inc easingly used in a a ie y o disciplines. Eye-
acking echnology allows di ec and con inuous measu emen o o e isual a en ion. Eye
mo emen s du ing language pe cep ion migh p o ide beha iou al da a supplemen a y o eac ion
ime measu es.
In he ollowing sec ions, eye- acking esea ch in dea s udies will be sho ly e iewed o gi e a
gene al pic u e o he possibili ies o e ed by his echnique and o pinpoin he use ha he cu en
esea ch has done o eye mo emen da a. A desc ip ion o he di e en measu es o eye mo emen s
will be ou lined. Fo he cu en doc o al hesis, eye-mo emen da a we e collec ed wi h he
pu pose o ob aining in o ma ion abou whe e o e a en ion is d i en when a dea pe cei e is
a ending SSS.

VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
54
1.4.1 Measu es o eye mo emen s.
Eye-mo emen e en s can be desc ibed in o e a hund ed o di e en measu es. Eye- acking
measu es can be g ouped in ou main classes: mo emen measu es, posi ion measu es, nume osi y
measu es, and la ency and dis an measu es (Holmq is e al., 2011).
Mo emen measu es, which ack eye mo emen s h ough space, p o ide in o ma ion abou
di ec ion, ampli ude, eloci y, accele a ion, shape, scanpa h compa ison, a eas o in e es , and
ansi ion. Posi ion measu es p o ide in o ma ion wi h espec o whe e pa icipan s a e looking
(basic posi ion measu es), he ex en o which gaze da a a e ocused o dis ibu ed (posi ion
dispe sion measu es), he simila i y in he posi ion o wo g oups o gaze da a (posi ion simila i y
measu es), he du a ion o he gaze in a de e mined posi ion (posi ion du a ion measu es), and how
pupil dila es looking a a posi ion (posi ion dila ion measu es). Nume osi y measu es p o ide
numbe , p opo ion o a e o coun able eye-mo emen e en s, such as saccades, glissades,
mic osaccades, smoo h pu sui , blinks, ixa ions, dwells, ansi ions, eg essions and some o he s.
La ency and dis ance measu es con ey ime and space in o ma ion o an eye-mo emen e en
ela ed o ano he e en , espec i ely. Speci ically, la ency measu es conce n ime delay, eco ding
he ime be ween he on- o he o se o an eye-mo emen e en o he on- o o se o ano he
e en , while dis ance measu es conce n he dis ance om one poin o ano he a he same ime.
Two basic eye- acking e en s a e saccades and ixa ions. Saccades and ixa ions can be calcula ed
di ec ly om he aw da a samples, h ough algo i hms based on posi ion, eloci y and accele a ion
da a. Saccades a e apid mo emen s o he eyes wi h eloci ies as high as 500º pe second, du ing
which eyes a e less sensi i e o isual inpu (saccadic supp ession). Be ween he saccades, he eyes
emain app oxima ely in he same posi ion du ing ixa ions, when sensi i i y o he isual inpu is
high. Fixa ions a e conside ed eliable when hey a e longe han a h eshold o 70-80 milliseconds
INTRODUCTION
55
(ms). The du a ion o a saccade depends on he dis ance co e ed, which usually is sho e in eading
asks and longe in scene pe cep ion asks (Ab ams, Meye , & Ko nblum, 1989).
Saccades a e equen because o he limi a ions o he acui y o ou isual sys em. Acui y is e y
good in he o eal egion — he cen al 2º o ision— and is p og essi ely educed in he pa a o eal
egion —ex ending om 2º o 5º om he eye ixa ion. Acui y is u he educed in he pe iphe al
egion, beyond 5º om he ixa ion poin . Depending on i s pe cep ual cha ac e is ics, a s imulus
in he pe iphe y can equi e a saccadic mo emen o be cen ally pe cei ed and ecognised, o i
can be iden i ied h ough pe iphe al ision. Fo example, in eading asks, a la ge le e o an objec
can be pe iphe ally iden i ied (Polla sek, Rayne , & Collins, 1984), whe eas a no mal-size wo d
could be mo e easily disce ned by making a saccade and being pe cei ed in he o eal egion
(Rayne & Mo ison, 1981).
1.4.2. Eye- acking in dea s udies.
Eye- acking s udies wi h dea obse e s ha e in es iga ed how a en ion is dis ibu ed ac oss he
isual ield when p ocessing language in eading o in sign-language communica ion. Eye- acking
da a p o ided u he e idence o he obse a ions ela ed o he inc eased pe iphe al ision o
dea obse e s, manly na i e dea signe s, ound in isual a en ion s udies (see pa ag aph 1.3.2.2).
In eading asks, skilled dea eade s, diagnosed wi h a se e e o p o ound hea ing loss, wi h ea ly
onse o dea ness, had enhanced pe cep ual span compa ed o hea ing pee s, wi h longe saccades
and less eg essions back in o he ex (Bélange , Sla e y, Maybe y, & Kei h, 2012).
In sign language communica ion, a main issue conce ns he a ea ha dea indi iduals isually
a end o when looking a someone signing. In hese s udies, pa e ns o gaze ixa ions o skilled
dea signe s wi h na i e o nea ly na i e knowledge o sign language a e compa ed o pa e ns o
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
56
gaze ixa ions o la e o naï e signe s and expe hea ing signe s. Dea pe cei e s ha e been ound
o ixa e mainly he ace a ea du ing comp ehension o signed communica ion. This was ound
bo h when messages in sign language we e p oduced li e by a signe (Emmo ey, Thompson, &
Col in, 2009) and when sign language was ideo- eco ded and p esen ed on a sc een (Ag a io is,
Canaga ajah, Bull, & Dye, 2003; Mui & Richa dson, 2005). Di e ences eme ged in he a ea o
he ace a ended o: i was a ound he eyes when pe cei ing sign language p oduced li e by a
signe and a ound he mou h when a ending o ideo- eco ded sign language con en (Ag a io is
e al., 2003). Fu he mo e, mo e equen ixa ions owa ds he mou h we e de ec ed in naï e
signe s, compa ed o na i e signe s, o pick up addi ional in o ma ion con eyed by mou hing
(Emmo ey e al., 2009). Resul s o hese s udies sugges ha pe iphe al ision is adequa e o
pe cei e signs and body mo emen s ha occu away om he ace egion o he signe .
Simila ly, a s udy ha analysed SSS pe cep ion (De Filippo & Lansing, 2006) ound ha signs
we e mos ly pe iphe ally pe cei ed e en when hey we e undamen al o disambigua e he sen ence
meaning. Impo an ly, SSS was p esen ed wi h no sound, meaning ha only he a iables o he
isual linguis ic componen s, signs and lip mo emen s, we e included in his expe imen .
Eye mo emen s ha e also been explo ed as a ma ke o dea s uden s’ a en ion in class oom
con ex s. The p e e ence o isualising a lec u e p esen ed on a ideo-sc een by an ins uc o in
SSS o in e p e ed in sign language was es ed ac oss h ee g oups o s uden s, hea ing s uden s,
skilled dea signe s and new signe s and co ela ed o lea ning (Ma scha k e al., 2005). Two
condi ions o lec u es we e compa ed. In he i s condi ion, he lec u e was signed by he ins uc o
himsel using SSS (simul aneous speech and signing). In he second condi ion, he lec u e was
p esen ed by he same ins uc o , bu spoken only and in e p e ed by an expe ienced educa ional
sign language in e p e e . When he lec u e was also in e p e ed in sign language, skilled signe s’
INTRODUCTION
57
isual gaze was mainly alloca ed o he in e p e e egion, bu new signe s spli hei isual a en ion
be ween he ins uc o and he in e p e e , and hea ing s uden s kep hei isual gaze on he
ins uc o s, shi ing some a en ion away om he ins uc o and owa ds he in e p e e . The wo
g oups o dea s uden s did no di e in hei lea ning unde any condi ion (Ma scha k e al., 2005):
albei dea s uden s came in o he class oom wi h less con en knowledge and sco ed lowe on
lea ning assessmen s, hey lea ned jus as much, p opo ionally, as hei hea ing pee s in bo h
condi ions. In e es ingly, in hese la e s udies (De Filippo & Lansing, 2006; Ma scha k, e al.,
2005), eye-mo emen da a we e ela ed o comp ehension and lea ning.

CHAPTER 3
STUDY 1: AN EYE-TRACKING STUDY ON THE PERCEPTION AND
COMPREHENSION OF UNIMODAL AND BIMODAL LINGUISTIC INPUTS BY
DEAF ADOLESCENTS
CHAPTER 4
STUDY 2: INFERENCING IN DEAF ADOLESCENTS DURING SIGN-
SUPPORTED SPEECH COMPREHENSION
CHAPTER 5
STUDY 3: THE ROLE OF MULTIPLE ARTICULATORY CHANNELS OF
SIGN-SUPPORTED SPEECH REVEALED BY VISUAL PROCESSING
Pa 2
Expe imen al Resea ch
Chap e 3
S udy 1: An Eye- acking S udy on he Pe cep ion and
Comp ehension o Unimodal and Bimodal Linguis ic Inpu s by Dea
Adolescen s
Eliana Mas an uono, Da id Saldaña, and Isabel R. Rod íguez-O iz
Depa amen o de Psicología E olu i a y de la Educación, Uni e sidad de Se illa, Spain
This esea ch was suppo ed by he Eu opean Union’s Se en h F amewo k P og amme o
esea ch, echnological de elopmen and demons a ion unde g an ag eemen no 316748.
Re e ence:
Mas an uono, E., Saldaña, D., & Rod íguez O iz, I. (2017). An eye- acking s udy wi h dea
adolescen s on he e icacy o sign-suppo ed speech. F on ie s in Psychology, 8(1044).
doi:10.3389/ psyg.2017.01044
EXPERIMENTAL RESEARCH
69
Abs ac
An eye acking expe imen explo ed he gaze beha iou o dea indi iduals when pe cei ing
language in spoken and sign language only, and in sign-suppo ed speech. Pa icipan s we e
dea (n = 25) and hea ing (n = 25) Spanish adolescen s. Dea s uden s we e p elingually
p o oundly dea indi iduals wi h cochlea implan s used by age 5 o ea lie , o p elingually
p o oundly dea na i e signe s wi h dea pa en s. The e ec i eness o sign-suppo ed speech
has a ely been es ed wi hin he same g oup o child en a discou se-le el comp ehension.
He e, ideo- eco ded ex s, including spa ial desc ip ions, we e al e na ely ansmi ed in
spoken language, sign language and sign-suppo ed speech. The capaci y o hese
communica i e sys ems o equalise comp ehension in dea pa icipan s wi h ha o spoken
language in hea ing pa icipan s was es ed. Wi hin-g oup analyses o dea pa icipan s es ed
i he bimodal linguis ic inpu o sign-suppo ed speech a ou ed discou se comp ehension
compa ed o unimodal languages. Dea pa icipan s wi h cochlea implan s achie ed equal
comp ehension o hea ing con ols in all communica i e sys ems while dea na i e signe s wi h
no cochlea implan s achie ed equal comp ehension o hea ing pa icipan s i es ed in hei
na i e sign language. Comp ehension o sign-suppo ed speech was no inc eased compa ed o
spoken language, e en when spa ial in o ma ion was communica ed. Eye mo emen s o dea
and hea ing pa icipan s we e acked and da a o dwell imes spen looking a he ace o body
a ea o he sign model we e analysed. Wi hin-g oup analyses ocused on di e ences be ween
na i e and non-na i e signe s. Dwell imes o hea ing pa icipan s we e equally dis ibu ed
ac oss uppe and lowe a eas o he ace while dea pa icipan s mainly looked a he mou h
a ea; his could enable in o ma ion o be ob ained om mou hings in sign language and om
lip eading in sign-suppo ed speech and spoken language. Few ixa ions we e di ec ed owa ds
he signs, al hough hese we e mo e equen when spa ial language was ansmi ed. Bo h
na i e and non-na i e signe s looked mainly a he ace when pe cei ing sign language,

VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
70
al hough non-na i e signe s looked signi ican ly mo e a he body han na i e signe s. This
dis ibu ion o gaze ixa ions sugges ed ha dea indi iduals – pa icula ly na i e signe s –
mainly pe cei ed signs h ough pe iphe al ision.
Keywo ds: eye- acking, dea s uden s, cochlea implan s, na i e signe s, discou se-le el
comp ehension, sign-suppo ed speech, pe iphe al ision.
Chap e 4
S udy 2: In e encing in Dea Adolescen s du ing Sign-Suppo ed
Speech Comp ehension
Eliana Mas an uono, Da id Saldaña, and Isabel R. Rod íguez-O iz
Depa amen o de Psicología E olu i a y de la Educación, Uni e sidad de Se illa, Spain
This esea ch was suppo ed by he Eu opean Union’s Se en h F amewo k P og amme o
esea ch, echnological de elopmen and demons a ion unde g an ag eemen no 316748.
Re e ence:
Mas an uono, E., Saldaña, D., & Rod íguez-O iz, I. (in p ess). In e encing in dea
adolescen s du ing sign-suppo ed speech comp ehension. Discou se P ocesses. DOI:
10.1080/0163853X.2018.1490133
EXPERIMENTAL RESEARCH
73
Abs ac
We es ed he capabili y o dea adolescen s, including a g oup o use s o cochlea implan s,
o gene a e in e ences du ing spoken language comp ehension, and whe he hey bene i ed
om he use o sign-suppo ed speech (SSS). S imuli consis ed o wen y- ou sho ideo-
eco ded ex s in spoken language and in SSS. Pa icipan s esponded o li e al and in e en ial
mul iple-choice ques ions. In spoken language, cochlea implan use s had mo e di icul y in
p ocessing in e en ial han li e al in o ma ion and ound p edic i e in e ences ha de han
associa i e in e ences. The le el o spoken language p o iciency was ela ed o in e ence
gene a ion, especially o p edic i e in e ences. Simila ly, dea na i e signe s had mo e
di icul ies in gene a ing p edic i e in e ences, al hough SSS inc eased hei comp ehension.
Lip eading skills and wo king memo y we e posi i ely ela ed o accu acy in SSS. The
inclusion o SSS only had a posi i e impac on he comp ehension o na i e signe s. Resul s
sugges ha cochlea implan use s would bene i om an in e en ion o enhance e bal skills.
Keywo ds: spoken language comp ehension, sign-suppo ed speech, p edic i e in e ences,
associa i e in e ences, na i e signe s, cochlea implan use s.
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
80
Pa icipan s we e adolescen s, aged be ween 12 and 19 yea s. This age ange allowed he es ing
o pa icipan s who had comple ed he pe iod o de elopmen al language acquisi ion.
Mo eo e , all pa icipan s who we e CI use s we e long- e m use s by he ime hey ook pa
in his s udy.
5.1 Summa y o esul s
In Expe imen 1, comp ehension o SSS was compa ed o comp ehension o spoken language
only and sign language only. Comp ehension o dea pa icipan s in he di e en modali ies
was compa ed o comp ehension o spoken language by hea ing-age pee s. The use o eye
acking aimed o e eal whe e dea pa icipan s alloca ed hei o e a en ion when a ending
o language in di e en modali ies. Al hough SSS did no nega i ely a ec comp ehension,
compa ed o spoken language, he esul s did no indica e imp o ed comp ehension ei he , bo h
o pa icipan s o he CI o he LSE g oups. CI use s achie ed he same comp ehension sco es
as hea ing s uden s in spoken language and SSS, while pa icipan s in he LSE g oup sco ed
below hea ing-age pee s in hese wo modali ies, al hough hey achie ed he same le el o
comp ehension when a ending o s imuli in hei na i e sign language. These esul s
highligh ed he bene i s in spoken language comp ehension gained by using CIs, while no
e ec s we e e idenced o he use o SSS. We had hypo hesized ha SSS, because o i s spa ial
na u e, would especially a ou he comp ehension o spa ial desc ip ions included in he ex s.
Con a y o expec a ions, he use o SSS did no enhance comp ehension compa ed o spoken
language when ocusing he analysis on spa ial in o ma ion ei he .
The eye acking da a p o ided howe e in e es ing esul s. They con i med p e ious esea ch
in which he ace o he sign model was he a ea p ima ily a ended o by all dea pe cei e s —
no only na i e signe s—, du ing sign language pe cep ion (Emmo ey e al., 2009), while he
signs we e a ended o ia pe iphe al ision. G ea e ocus on he lowe a ea o he ace o he

SUMMARY AND DISCUSSION OF RESULTS
81
sign model was de ec ed, consis en wi h o he s udies in which sign language was ansmi ed
h ough ideo eco dings (Ag a io is e al., 2003; Mui & Richa dson, 2005). Al hough all dea
pa icipan s mainly looked a he ace a ea du ing sign language pe cep ion, na i e signe s
signi ican ly di e ed om non-na i e signe s in ha hey looked owa ds he signs o a sho e
o e all pe iod. This di e ence be ween na i e and non-na i e signe s was no de ec ed in SSS,
du ing which na i e signe s looked a he hand longe han hey did when pe cei ing sign
language. This was a ibu ed o he ac ha SSS is an a i icial sys em and canno be
au oma ized as a na u al language, so he use o pe iphe al ision o pe cei e signs p esen ed
some di e ences in he wo modali ies.
Expe imen 2 ex ended he in es iga ion on discou se comp ehension by dea adolescen s and
he e ec i eness o SSS o he comp ehension o li e al and in e en ial in o ma ion, speci ically
associa i e and p edic i e in e ences. Cogni i e unc ions, non e bal IQ and wo king memo y,
as well as linguis ic a iables, lip eading and p o iciency in spoken and sign language, we e
analysed as possible p edic o s o language comp ehension. In p e ious s udies (Clea y, Pisoni,
& Gee s, 2001; Pisoni e al., 2008; Pisoni & Gee s, 2000), cogni i e unc ioning, in pa icula
execu i e unc ions, has been used o explain indi idual di e ences among dea child en who
a e non-na i e signe s —and who, ine i ably, su e ed om an ea ly dep i a ion o linguis ic
inpu — compa ed o dea child en who a e na i e signe s. Consis en wi h indings ela ed o
hea ing indi iduals (Cu ie & Cain, 2015), pa icipan s wi h CIs p ocessed in e en ial
in o ma ion less accu a ely han li e al in o ma ion. P edic i e in e ences we e less accu a e
han associa i e in e ences in pa icipan s om bo h he CI and he LSE g oup. P o iciency in
spoken language con ibu ed o explain p edic i e in e ence gene a ion in CI use s. I was
sugges ed ha p edic i e in e ences we e mo e challenging as hey equi e a mo e comple e
comp ehension o he ex han associa i e in e ences. In ac , p edic i e in e ences in ol e he
in eg a ion o mo e pieces o in o ma ion in he ex , while o gene a ing associa i e in e ences
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
82
i migh be su icien o only g asp a key piece o in o ma ion in he ex and connec i o p io
wo ld knowledge. The use o SSS did no inc ease comp ehension in CI use s, sugges ing ha
hese pa icipan s we e mainly ocused on he o ally ansmi ed message. On he con a y, SSS
did enhance he pe o mance o na i e LSE signe s, compa ed o spoken language. Wo king
memo y capaci y posi i ely a ec ed comp ehension o SSS bu did no ha e e ec s on spoken
language. Lip eading played a signi ican ole in comp ehension o li e al and in e en ial
in o ma ion ac oss all g oups o pa icipan s.
In he i s wo expe imen s, ou main pu pose was o e alua e he e ec i eness o SSS in
inc easing discou se comp ehension and in e en ial p ocessing by dea adolescen s.
Expe imen s 3 and 4 we e mo e essen ially cen ed on ga he ing e idence o he espec i e
con ibu ion o lip mo emen s and signs in ansmi ing in o ma ion du ing SSS pe cep ion,
and on cla i ying whe he signs a e ac ually a ended o, e en i i is pe iphe ally. Eye- acking
da a in he p e ious expe imen s had e ealed a s ong p e e ence o looking a he ace when
a ending o discou se in SSS, simila ly o wha has been ound in sign language (Expe imen
1). This gaze beha iou migh be a consequence o he majo pe cep ual di icul y o disce ning
lip mo emen s compa ed o signs, some hing ha would lead one o ocus o e a en ion
owa ds he lip mo emen s, pe cei ing in o ma ion om signs ia pe iphe al ision (i).
Al e na i ely, i migh be ha signs a e simply o e idden a he han pe iphe ally pe cei ed,
and all in o ma ion is ob ained om spoken/lip ead wo ds (ii).
In Expe imen 3, he isual p esen a ion o SSS on a sc een was manipula ed and adop ed wo
modes o es hese hypo heses. Fo es ing he pe cep ual hypo hesis (i), he lip a ea was
magni ied compa ed o he ches a ea (magni ied condi ion). This way, lip mo emen
pe cep ion was acili a ed, and o e a en ion could be mo e balanced be ween he ace/lip a ea
and ches /signing a ea. Fo es ing he e ec i e use o pe iphe al ision in pe cei ing signs (ii),
SUMMARY AND DISCUSSION OF RESULTS
83
an in e ac i e gaze-con ingen applica ion o he eye acke ha limi ed he use ul ield o
ision was implemen ed. The gaze-con ingen display only allowed he a ea o he sc een
a ound he pa icipan ’s locus o ixa ion o be isible (gaze-con ingen condi ion). A any ime,
pa icipan s we e able o ob ain in o ma ion om one linguis ic channel only, ei he he ace/lip
mo emen s a ea o he ches /signing a ea. In he magni ied condi ion (i), pa icipan s o he
LSE g oup and, mo e gene ally, pa icipan s wi h poo e lip eading skills and CI use s wi h
lowe sco es in wo king memo y capaci y, looked mo e equen ly owa ds he signs, compa ed
o wha hey did in no mal isual condi ions. On he o he hand, he gaze-con ingen window
(ii) a ec ed gaze beha iou and accu acy o all g oups o pa icipan s, wi h an inc eased numbe
o ixa ions owa ds he signing a ea, lowe accu acy, and longe eac ion imes han in no mal
isual condi ions. These la e esul s migh sugges ha dea pa icipan s bene i om he
bimodal channel o in o ma ion and ha hey eso o signs o in eg a e, con i m o subs i u e
in o ma ion om spoken/lip ead wo ds. When he sou ces o in o ma ion om SSS a e no
concu en ly a ailable, comp ehension is hinde ed. Howe e , hese esul s mus be ca e ully
in e p e ed: hey migh ha e been d i en by he expe imen al ideo p esen a ion o he s imuli,
which led pa icipan s o isualise he un amilia display di e en ly, ega dless o he linguis ic
channel om which hey ac ually ge in o ma ion.
Expe imen 4 aimed o cla i y whe he dea pe cei e s eally eso ed o signs o ob ain
in o ma ion, beyond spoken/lip ead wo ds. This objec i e was pu sued by designing s imuli
whe e speech and sign in o ma ion was misma ched, wi h signs ca ying a di e en meaning
om he spoken wo ds. Al hough hey we e ins uc ed o pay a en ion o he o ally ansmi ed
message, pa icipan s o he CI g oup alloca ed o e a en ion mo e equen ly owa ds he
signs in he misma ch han in he ma ching condi ion. The e we e also slowe and less accu a e,
because hey o en selec ed he ep esen a ion e e ing o he sign. Na i e LSE signe s had a
d ama ic d op in accu acy in he misma ching condi ion, mos ly e e ing o he signs, e en i
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
84
hei gaze beha iou and eac ion imes did no signi ican ly change ac oss condi ions. These
esul s migh sugges ha signs we e p ocessed by all pa icipan s: longe eac ion imes and
mo e ixa ions owa ds he sign in CI use s in he misma ching condi ion indica e ha hey
p ocessed he inconsis ency be ween speech and signs, and ha hey occasionally elied on he
signs when missing in o ma ion om spoken/lip ead wo ds. When pe cei ing SSS in no mal
condi ions, CI use s migh he e o e be engaged in he seman ic in eg a ion o signs and speech.
As o na i e signe s, he lack o e ec s in gaze beha iou and eac ion imes, despi e he
dec ease in accu acy when p ocessing he misma ching condi ion, showed ha pa icipan s
ob ained in o ma ion mos ly om signs, igno ing spoken wo ds.
5.2 Discussion
5.2.1 Discussion o he indings o cochlea implan use s.
O e all, in CI use s, discou se comp ehension was no signi ican ly imp o ed wi h SSS
compa ed o he use o spoken language only (Expe imen 1), e en when i in ol ed he highe -
le el cogni i e p ocesses equi ed by in e ence gene a ion (Expe imen 2). Al hough hese
pa icipan s, implan ed be o e he age o i e, had good- o-p o icien skills in sign language and
educa ional expe iences wi h SSS, hey did no bene i om he ein o ced in o ma ion
p o ided by he bimodal linguis ic channel o SSS. Comp ehension by CI use s o spoken
language and SSS was equi alen o comp ehension by hea ing pee s o spoken language
(Expe imen 1). I migh be he case ha he e was li le oom le o imp o ing comp ehension
using SSS, possibly due o he gene al di icul y o he ask, which in ol ed he cons uc ion o
spa ial si ua ion models. Despi e he lack o a ou able esul s o he use o SSS wi h CI use s,
eye- acking da a du ing p ocessing a omic sen ences in isual condi ions cons aining he
pe iphe al ision indica ed ha hese pa icipan s alloca ed a en ional esou ces owa d signs
(Expe imen 3) and, when lexical i ems we e con lic ing, hey equen ly elied on signs, e en
hough ins uc ed o e e o spoken wo ds (Expe imen 4). Join ly conside ed, hese indings
SUMMARY AND DISCUSSION OF RESULTS
85
e eal ha CI use s do eso o he isual linguis ic sou ce o e ed by signs in SSS. The
a en ion o he signed lexicon ound in he expe imen s using a omic sen ences as s imuli,
oge he wi h he longe eac ion imes in he comp ehension ask when he bimodal inpu o
SSS was expe imen ally dis up ed, can be ela ed o he cogni i e phenomenon ha has been
iden i ied as code-blending acili a ion (Emmo ey e al., 2012 ), edundan signals e ec s
(Mille , 1986) o he dual coding heo y (Pai io, 2010; Pai io e al., 1988). This phenomenon
is obse ed when wo s imuli wi h he same meaning simul aneously p esen ed ia bimodal
channels in ol e a seman ic in eg a ion ha leads pe cei e s o p ocess wo s imuli mo e easily
and quickly han hey would a single s imulus, because he edundan in o ma ion is combined
and coac i a es a esponse. The coac i a ion o unc ionally independen bu in e connec ed
mul imodal sys ems would c ea e a s onge connec ion in memo y and he in o ma ion would
be be e e ained (Pai io, 2010). This e ec has been ound in hea ing-impai ed indi iduals
who a e used o connec ing audi o y and isual linguis ic s imuli h ough lip eading o signs,
bu i has no been de ec ed in no mal-hea ing indi iduals o in indi iduals wi h speci ic
language impai men ( an Be kel- an Hoo e al., 2016). Recen indings ela ed o single-wo d
acquisi ion, ha e ound ha bimodal inpu p o ides a suppo o ocabula y acquisi ion o
comp ehension o no el o pseudowo ds (Giezen, 2011; Giezen e al., 2014; an Be kel- an
Hoo e al., 2016).
Why did we no ind his ad an age a a discou se le el (Expe imen 1) o in sho ex s
(Expe imen 2)? The explana ion migh be connec ed o he g ea e numbe o a iables
(g amma knowledge, sho - e m memo y, wo king memo y, o sus ained a en ion) ha a e
in ol ed in discou se comp ehension, and he he e ogenei y in cogni i e and linguis ic
pe o mance wi hin he s uden s wi h CIs. Discou se and long-sen ence comp ehension equi e
mas e y o he g amma o a language and SSS does no suppo his goal. The g amma ical
skills o CI use s a e equen ly below age-app op ia e s anda ds, e en when ocabula y size is

VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
86
equa ed o ha o hea ing-age pee s (Caselli e al., 2012; Duchesne e al., 2009). Fo his hesis,
due o ime limi a ions, pa icipan s’ g amma ical skills we e no assessed. Only a ew measu es
o linguis ic and cogni i e skills we e collec ed and co ela ed o language comp ehension:
non e bal IQ, wo king memo y, spoken ecep i e ocabula y size, lip eading skills, and
p o iciency in spoken and sign language comp ehension. Wi h espec o he ecep i e
ocabula y measu e, no a iance among pa icipan s, wi h and wi hou CIs, was ound, wi h
only ew o hem pe o ming abo e baseline. Due o he lack o a iance, in mos o he
expe imen s (Expe imen s 2, 3, and 4), he measu e o spoken ecep i e ocabula y could no
be included as a p edic o o comp ehension. Gi en he poo pe o mance ac oss all
pa icipan s, spoken ecep i e ocabula y ep esen ed a subs an ial common di icul y o his
popula ion, and eso ing o sign ocabula y would appea o be well-mo i a ed.
O he linguis ic skills a ec ed comp ehension in CI use s. P o iciency in spoken language
comp ehension was especially ele an in inc easing he gene a ion o p edic i e in e ences
ha , mo e han o he ypes o in e ence, equi e a ull unde s anding o he ex and depend on
he in eg a ion o mo e pieces o in o ma ion ac oss he en i e ex (Expe imen 2). Lip eading
was also an impo an p edic o o comp ehension ac oss all pa icipan s, no only CI use s,
wi h mo e p o icien lip eade s achie ing highe le els o comp ehension (Expe imen s 2 and
4) and poo e lip eade s ixa ing mo e on he signs in he magni ied condi ion (Expe imen 3).
Along wi h linguis ic skills, CI use s we e also in luenced by wo king memo y: pa icipan s
wi h a smalle wo king memo y capaci y looked mo e equen ly a signs in he magni ied
isual condi ion, as poo lip eade s did (Expe imen 3). Fu he mo e, hese pa icipan s elied
mo e equen ly han hei pee s wi h g ea e wo king memo y on signs, compa ed o speech,
o ob ain in o ma ion when sign and speech misma ched (Expe imen 4). I migh be ha he
pa icipan s wi h poo e wo king memo y in his sample ecalled i ems in he isual-manual
SUMMARY AND DISCUSSION OF RESULTS
87
modali y mo e easily han in he audi o y-o al modali y.
Despi e he e ec i e ein o cemen ha signs in SSS p o ided o pa icipan s wi h CIs wi h
poo e linguis ic skills and wi h wo king memo y, he o e all amoun o in o ma ion gained by
CI use s did no imp o e wi h SSS. These esul s a e in con as wi h some ecen indings
ela ed o he success ul use o SSS wi h CI use s in class oom con ex s (Blom & Ma scha k,
2015; Blom, Ma scha k, & Machme , 2016). SSS was ound o be mo e e ec i e han spoken
language when ma e ials wi h g ea e complexi y o con en we e p oposed, bu no wi h
ma e ials wi h simple con en (Blom & Ma scha k, 2015). Fu he mo e, SSS inc eased
comp ehension in compa ison o spoken language in noisy con ex s, such as class oom con ex s
wi h mul i- alke babble, whe e much audi o y in o ma ion can easily be missed o mishea d
(Blom, Ma scha k, & Machme , 2016). In ou s udies, es ing ma e ials we e no di e en ia ed
o con en complexi y and s imuli we e p esen ed ia ideo eco dings in quie ooms wi h
good acous ic accessibili y o ensu e ha pa icipan s, indi idually es ed, pe cei ed he same
s imuli in analogous condi ions. Howe e , gi en he a en ion ha pa icipan s de o ed o signs,
especially pa icipan s wi h poo e linguis ic skills and wo king memo y, i is plausible ha
SSS may make a di e ence in suppo ing comp ehension in asks wi h complex con en and
opic-speci ic ocabula y, and in noisy con ex s.
5.2.2 Discussion o he indings o na i e LSE signe s.
Fo na i e signe s, comp ehension was expec ed imp o e in SSS compa ed o spoken language
only, hanks o he signs. Indeed, na i e signe s had be e p oduc ion o p edic i e in e ences,
which en ail a mo e comple e comp ehension o he o e all con ex compa ed o o he
in e en ial p ocesses (Expe imen 2). The ele ance o signs o hese pa icipan s was
con i med by he o ien a ion o isual a en ion owa ds hem when isual condi ions we e
manipula ed (Expe imen 3). Mo eo e , when speech and sign misma ched, na i e signe s
showed hei eliance on signs, equen ly e e ing o hem a he han o spoken /lip ead wo ds
VISUAL PERCEPTION AND SIGNED ORAL LANGUAGE IN DEAFNESS
88
(Expe imen 4).
Howe e , in Expe imen 1, SSS did no impac signi ican ly on comp ehension compa ed o
spoken language only. This migh be due o he di icul y and o he speci ici y o he ask,
which could be mo e sui ably ansmi ed in sign language, as he ex comp ehension equi ed
he cons uc ion o a spa ial si ua ion model. While SSS did no make comp ehension by na i e
signe s equi alen o he comp ehension o spoken language by hea ing pee s, sign language
did (Expe imen 1). In conclusion, al hough a ious esul s o ou hesis indica e ha SSS
inc eases he comp ehension o na i e signe s compa ed o spoken language, i is impo an o
s ess ha SSS is no a na u al language and can ha dly gua an ee he same comp ehension ha
na i e signe s can achie e in hei na i e sign language. Di e ences in p ocessing SSS and sign
language we e no only e ealed by accu acy sco es, bu also by he spa ial dis ibu ion o isual
a en ion in na i e and non-na i e signe s.
5.2.3 Spa ial dis ibu ion o isual a en ion du ing SSS pe cep ion.
The mos inno a i e aspec o his hesis conce ns he combina ion o comp ehension and eye-
acking da a du ing language pe cep ion in SSS. As in sign language pe cep ion, dea
pa icipan s mos ly ixa ed on he ace a ea when a ending o SSS (Expe imen 1). In sign
language, he e is clea e idence ha pa icipan s a e pe cei ing signs pe iphe ally. In SSS,
howe e , whe e a bimodal channel o in o ma ion is a ailable, i was no clea ha pa icipan s
—pa icula ly hose wi h unc ional hea ing— pe cei e signs ia pe iphe al ision. I migh be
ha hey a e jus igno ing he signs and ob aining all he in o ma ion om speech and
lip eading. The use o a mo ing window ha limi ed he use ul ield o ision o ei he he ace
o he signing a ea (Expe imen 3), and he implemen a ion o a pa adigm wi h inconsis en
meanings be ween sign and speech (Expe imen 4), p o ided e idence o suppo he hypo hesis
ha pa icipan s wi h CIs a e also ac i ely a ending o he in o ma ion om signs.
SUMMARY AND DISCUSSION OF RESULTS
89
The indings o hese expe imen s also d aw a en ion o di e ences in isual p ocessing o SSS
and sign language, and be ween na i e and non-na i e signe s. Dea na i e signe s, when
pe cei ing sign language, had ewe gaze de ia ions owa ds he signs han dea non-na i e
signe s (Expe imen 1). This is consis en wi h ea lie indings ha a ibu ed his di e ence o
a mo e de eloped pe iphe al ision in na i e signe s (Ag a io is e al., 2003). On he o he hand,
no di e ences we e de ec ed be ween na i e and non-na i e signe s’ gaze beha iou in SSS
(Expe imen 1). This was a ibu ed o he a i iciali y o SSS, which canno be acqui ed as a
na u al language. Na i e signe s ha e no au oma ized he use o pe iphe al ision in complex
long ex s as in sign language pe cep ion. Howe e , eye mo emen da a om Expe imen 1
e e ed o long ime windows, which acked he eyes ac oss he en i e leng h o he s imuli,
app oxima ely 100 seconds each. Howe e , when e iewing ixa ions o e sho e ime
windows and ex s, di e ences be ween na i e and non-na i e signe s did eme ge in SSS: na i e
signe s looked less owa ds signs han non-na i e signe s when a ending o he basic sen ences
p esen ed in he baseline isual condi ion (Expe imen 3) and in he ime window o a c i ical
wo d (Expe imen 4). Al hough ixa ing on he ace a ea, na i e signe s, who we e ound o be
signi ican ly less expe lip eade s ha hei pee s wi h CIs, seemed no o pay a en ion o lip
mo emen s, e ie ing mos in o ma ion om he pe iphe ally pe cei ed signs. This occu ed
e en when pa icipan s we e explici ly ins uc ed o e ain o ally ansmi ed in o ma ion
(Expe imen 4). This accoun would con i m he di ision o labou hypo hesis p oposed in
Mi chell (1996), which con empla es a limi ed- esou ce model o a en ional esou ces. This
hypo hesis was well suppo ed by s udies in es iga ing how he spa ial a en ion ha spills o e
om isual sea ch asks is dis ibu ed (Dye e al., 2009; P oksch & Ba elie , 2002). While
hea ing indi iduals sa e le o e a en ional esou ces o p ocess in o ma ion a he ixa ion
poin a he han he pe iphe y (Beck & La ie, 2005), dea indi iduals would mos ly de o e
le o e a en ional esou ces o s imuli in he pe iphe al isual ield a he cos o cen ally

97
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