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Cueing with Children with Disabilities Affecting Language

Development

Donna A. Morere, Ph.D.Gallaudet University

Donna.Morere@gallaudet.eduDonna.Morere@verizon.net

NCSA 7/22/06ASHA CEU code SC-02

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The Plan

• Briefly review sources of language delays– ADHD– NLD– PLD– “Other”

• Address ways the first three affect deaf children and how CS can support their language development.

• Ways to adapt CS to optimize use with these children

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Some sources of lack of language development

• ADHD

• Nonverbal learning disability (NLD)

• Primary language disorder (PLD)

• “Other”– PDD/ Autism, cognitive deficits, vision problems

• Additionally, expressive use of both signs and Cued Speech may be affected by fine motor problems.

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ADHD

• Affects development of: – Language– Social skills– Behavior – emotional and adaptive– Academic skills.

• Commonly recognized symptoms include:– Inattention– Distractibility– Impulsivity– Over activity

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ADHD• Executive functioning deficits are often

overlooked. They include:– Poor organization– Difficulty learning from feedback– Difficulty developing and implementing effective

strategies– Difficulty altering approaches to tasks

• These symptoms are important as they affect the child’s ability to develop language and other skills regardless of attention.

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Organization

• Affects how the child stores information– If this is organized, it is like having information

filed so that it is easily located– If this is chaotic, as with the ADHD child, it is

like searching through a pile on the floor.

• Poorly organized information affects comprehension – Searching for the concept associated with the

word you are trying to understand • ____ _____ ____ /red/ ____ _____

– Putting the pieces together so they make sense

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Organization

• Poor organization also affects expression– Retrieval difficulties due to extensive searching for

the word needed to convey a concept• Response latencies may be quite extensive (minutes)

• During the search, the child may forget the rest of the content of what he wanted to say.

• The child may become distracted during retrieval.

• This uses up cognitive resources the child needs to process language and develop knowledge of the world.

– Organization of output.• Putting the pieces together so they make sense to the

listener. Often output is equally chaotic.

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ADHD: Special Impact on Deaf Children

• For a deaf/HOH child to receive information from the environment, s/he must be attending to the stimulus. – Especially important for the reception of language.– Deaf children cannot passively take in language

while attending to toys or other stimuli.

• Inattention may result in delays in learning language as the child may– completely miss information– receive incomplete information– have decreased exposure to language overall

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Impact of Language Delays on ADHD

• Delays in language development hinder behavioral management of ADHD – These generally teach the child to use language to

help manage their behavior. What do you do if they don’t have the language to use?

• Delays in language development may negatively affect development of the frontal lobes, the brain area implicated in ADHD.– Language and the frontal lobes develop

interactively

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Why CS for ADHD?

• Static presentation of cued language can provide language access that is not transient.– Information is not lost due to inattention.

• Stimuli remain available for times the child can attend.

– These can be set up to • Optimize organization of information, providing internal

structure

• Teach organizational skills.

– Simultaneous presentation of print and cues provides access to English and literacy regardless of attention

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Why CS for ADHD?

• CS through the air– Uses a limited space so that gaze/attentional shifts

are not required• ADHD kids often “lose their place” and can become

distracted when required to make gaze shifts.

• Due to the extensive visual space involved in signing, they may lose track of the signs.

– This also makes them more vulnerable to distractions.

– Supports linguistic sequential processing• Important for development of working memory, which

is used to compensate for comprehension difficulties.

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ADHD: How to Cue?

• When cueing with a child with ADHD, make sure s/he is paying attention. – Set up gentle signals to recall attention.

– Set up a behavioral contract to support attention.

– Start important information with his name.

• Repeat what you said the same way the first time she asks what you said. – She may not have seen it all. If she still doesn’t

get it, THEN, re-phase.

• Use the static strategies discussed later

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Nonverbal Learning Disability (NLD)

• NLD is a neurological disorder involving: – Difficulty with visual and spatial

information.

– Motor skills deficits

– Executive Functioning Deficits

– Social skills deficits

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NLD: Difficulty with visual and spatial information.

• Poor visuospatial organization, including difficulty with:– Visualization

– Tracking and processing of visuospatial information

– receptive and expressive spatial relations• e.g., location and movement of signs

• These deficits make receptive and expressive signing difficult

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NLD: Motor skills deficits

• Balance problems

• Poor coordination & motor sequencing– May have difficulty knowing where their limbs

are relative to their body– This may affect expressive signing– Clumsiness doesn’t help with peer relations.

• Difficulty with fine and complex motor skills – Affects expressive signing, cueing and

writing.

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NLD: Executive Functioning Deficits

• Problems similar the child with ADHD that will need similar interventions/modifications.

• NLD kids have particular problems related to:– Difficulty managing novel stimuli. – Difficulty “shifting”

• This makes transitions difficult – it is hard for him to stop one activity and switch to another.

– Inadequate planning and organizational skills.

– Difficulty learning from experience.

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NLD: Social Skills Deficits

• Difficulty understanding and using nonverbal communication– Facial expression, posture, tone of voice– The first two have significant impact on both

receptive and expressive signing, as they are important components of the linguistic message in ASL

• Poor social judgment and difficulty with social interactions.

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NLD & Social Skills

• These children can’t “read” others & have little understanding of common social expectations.

• They do not learn these things naturally and must be taught the cues and expectations involved in social situations.

• This has a major impact on understanding of receptive language regardless of the communication modality.

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NLD: Strengths and Weaknesses

• Hearing kids with NLD tend to excel on basic verbal skills, such as basic reading and spelling.

• This may not be as accessible to deaf children.

• They typically depend on verbal skills to function, but difficulty with:– Reading comprehension– Math (especially math reasoning)– Handwriting (may improve with increased practice)– Science.

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NLD and Cued Speech

1. Cued Speech is preferable to signs for language development as it is less dependant on visuospatial skills.

– Difficulty with the fine motor skills may affect expressive cueing

– They may be better able to receive and develop the formal language as Cued Speech has

• a minimal spatial component• a very limited set of formational components.

• photographs of CS on paper eliminate the spatial component

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NLD and Cued Speech

2. Cued Speech is also preferable to signs due to the impact “nonverbal” factors such as facial expression and body language.

– While these factors are important for connotation with CS, just as they are in any language, they do not represent components of the direct linguistic message as is the case with ASL.

– With CS, the child will have access to literal language and literacy despite ongoing difficulties with emotional and indirect communication.

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NLD and Cued Speech

3. Cued Speech also provides for the interventions related to organization and other executive functioning difficulties discussed under ADHD

– Language on posters or paper can be organized to provide external structure that they can incorporate.

– These items have the added advantage of accessing literacy when combined with print.

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NLD and Deafness

• Deaf children who are attempting to learn language using a dynamic visuospatial system, such as ASL, may demonstrate both the standard symptoms of NLD and secondary language deficits. – With intensive language stimulation, they may

develop adequate ASL skills, but may continue to be awkward in both receptive and expressive signing.

• With CS, basic language skills may become the relative strength typical of NLD kids.

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NLD and Communication

• Regardless of the interventions provided,

while some may develop language given

accessible input, deaf children with NLD are

likely to continue to have difficulties in

communication due to the problems with

facial expression and emotional tone that are

important for oral language as well as signed

or cued language.

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Primary Language Disorders (PLD)

• A PLD is indicated if there is– significantly impaired language development

relative to the language access provided – there are no conditions that would impair the

child’s ability to utilize that access, such as • Vision deficits (affecting receptive language)• Motor impairments (affecting expressive language)• Cognitive deficits or neurological impairments• Psychosocial functioning disturbances

• These children would likely have language deficits even with normal hearing.

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In Contrast to the Child with NLD, those with PLD

• Have difficulty with all communication modes

• May have adequate pragmatic skills – Often attempt to use gestures, pantomime, facial

expression, and posture to try to communicate

– May have enhanced awareness and use of these factors and try to use them to interpret incoming messages.

• They tend to have excellent static visual spatial skills and math may represent their best area of academic functioning.

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General Presentation of PLD

• These children have extreme difficulty understanding what both adults and children are trying to tell them

– They may be better able to understand adults than peers.

– They are often able to understand better if the person speaks/cues/signs slowly and uses simple, brief statements with frequent pauses.

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Presentation of the Deaf Child with PLD

1. Those with more severe disorders often appear confused or completely lost.

2. He may not follow classroom rules or instructions.a) Due to lack of understanding of what is required

rather than willful misconduct.

b) He may nod or otherwise seem to indicate understanding or demonstrate partial understanding of the rules, but may miss key elements, such as “not”.

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Presentation of the Deaf Child with PLD

3. She depends on non-language visual cues for information.

4. Attempts at expressive communicationa) are inadequate

b) incorporate more visual-gestural communication than ASL or CS

c) may include acting scenes out and drawing or other use of pictures.

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Presentation of the Deaf Child with PLD

5. He may seem to understand things one day and have “lost” them the next.

6. Those with developing language skills or a milder form of the disorder may a) seem slow to respond or

b) have delayed comprehension.

c) may have difficulty learning to read when compared to deaf peers from similar backgrounds.

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Working with a child with PLD• Cue Slowly!• Allow for processing time.• Use short, simple phrases.• Provide a consistent approach to work. • Remember that misbehavior may reflect

misunderstanding.• Monitor their attention.• Watch timing of class requirements and be alert

for signs of stress.• Encourage positive peer relationships• Provide non-language visual cues.

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Working with a child with PLD

• CUE Slowly!

– This is especially important if new vocabulary is being presented.

– Individuals with PLD can not process cueing at a normal rate, so if you cue quickly, they are likely to “see” only fragments of the message.

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Working with a child with PLD

• Allow for processing time. – Frequent pauses to give time to “catch up”

processing. – They may still working on the early part

of what you just said as you are completing your statement.

– Even if they depend on a few key words, they will need time to make sense of them.

– Give plenty of time to process before answering.

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Working with a child with PLD

• Use short, simple phrases and try to work within the vocabulary that you know they understand.

– Break information down into small chunks.

– When possible, use concrete words and give examples.

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Working with a child with PLD

• Support linguistic information with non-language visual cues.

– Pictures or drawings and programs such as BoardmakerTM and Writing With Symbols 2000TM enhance comprehension.

– Having objects being discussed present or doing “hands on” demonstrations is also helpful.

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Working with a child with PLD

• Cue, but allow a range of ways to communicate.– Remember, he WANTS to communicate with you.

He may • Try to cue, sign, gesture, pantomime or act out the object

or character he wishes to discuss• Use a few words to try to give you the general idea • Point, draw, or show you pictures.

– Keep a picture dictionary handy.• This can be used to clarify information he doesn’t

understand and for him to look for what he wants to say in the pictures.

– If there is a common set of problem words, make a picture communication chart so he can point to the word or concept he wants to convey. (food)

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Special Benefits of Cueing• One great thing about PLD kids is that

they usually have exceptional static visual skills. – They can process and remember things

that don’t move (like pictures) beautifully.

• BUT they need additional time to process information

• CS allows you to put phonemes on paper!– This provides unlimited processing time.– Digital photographs of cues associated

with pictures (to represent the concepts) and print (for literacy) play to their strength!

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Digital Cues: phonemes on paper

/ue/ /e/ /oo/ /i/ /uh/

/p/ /b/ /m/ /f/ /v/

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Organization

• Many children with language and other learning disorders (ADHD, NLD, etc.) have problems with organization– They often need training in strategies for

organizing information to more efficiently store it in memory.

– They need more structure in their lives in general, but can’t provide it for themselves.

– They need concrete visual cues to tell them when things are about to change and what is expected of them.

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Organizational Strategies

• Color coding of word types can help with grammar and sentence comprehension. – This is especially important if they have inadequate

understanding of basic language structure.

• Organizing information in categories is the most efficient way to organize of objects. – For basic vocabulary, present in semantic

categories (e.g., vehicles)– CS on paper offers accessible visual presentation of

groups and organizational strategies.

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Developing linguistic organization

Animals with 4 legs

horse dog rat

Great Dane ChihuahuaLabrador

• Kids develop knowledge based on exposure and correction.

• Pictures and digital cues can be added.• Charts with categories can be made.

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CS for Language Development in PLD

• Children with PLD need limited movement in visual communication.– CS has a small range of movement, and the

movement itself is irrelevant for most cues.

• Language stimuli should be available in a static format.– Cues on paper allow for static presentation of

phonemic information.

• PLD kids need ongoing review of vocabulary.– Cued worksheets (pictures, print & Cues) allow for

drills as desk work or homework: offer vocabulary.

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The Association Method• This method has been used by the DuBard

school for Language Disorders at USM (DuBard & Martin, 2000) with deaf children with PLD.

• It is a multisensory teaching method developed for children with severe language disorders.

• It begins with single phonemes identified by symbols using – Print, residual hearing, tactile, kinesthetic (through

writing and speaking), and speechreading input.

• It is assumed that each component available to the child will enhance his ability to understand and retain the information.

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The Association Method

• The phonemes and their symbols & graphemes are learned through structured drills and writing tasks presented in a sequential manner.– The child is required “say”, write, read, and

recognize each using speechreading and residual hearing (if any).

– First he masters the phonemes & their symbols in isolation.

– Written drills are necessary for development of automaticity, which is critical for fluent decoding of both speech and print.

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The Association Method

• Once sets of phonemes and their corresponding graphemes are mastered, they are then combined into– consonant-vowel pairs

– simple words with pictures to enhance association with meaning (vocabulary development).

• Ongoing repetition and review are used to ensure maintenance of previously learned material– New material always incorporates previously

learned phonemes, words, and structures.

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CS and the Association Method• CS can be used in the manner of the AM

– CS can also be used for face-to-face communication in visually unambiguous manner.

– The cues have intrinsic tactile-kinesthetic feedback through expressive cueing.

– The written AM drills can use pictures of cues to provide the phonemic information.

• Thus, a proven method for supporting language development in deaf PLD children can be combined with CS for a comprehensive language & literacy program

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Cues Represent Phonemes, Not Graphemes

• With CS, you can separate the letters from the sounds just as the AM symbols are used to represent the phonemes (sounds).– Thus, you can clearly demonstrate that the

sound /k/ (right) is associated with the letters “k” and “c”, and “ck” also sounds like this, and that “ch” may sound this way as well,

– but most of the time “ch” sounds like /ch/ (right)

• In this manner, the sounds, or phonemes, can be separated from the letters, or graphemes, by which they are represented in print.

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Digital Cues: Static decoding tasks

• Since movement is not required to understand cues, phonemes can be placed on paper in conjunction with the printed letter with which the child is learning to associate it.– This allows the child to practice the letter-sound

relationships in pencil and paper worksheets. • Instead of telling the child “the letter "b" sounds like /b/”

or learning a symbol for the phoneme

• They do worksheets that require them to associate the letter "b" with the phoneme /b/ visually represented by the cue.

– These can be repeated as necessary until mastery is achieved.

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Digital Cues: Static decoding tasks

• When a child writes the letters to match a string of digitally presented cues, he is essentially learning to “write to dictation” without the time constraints inherent in speech– the words only stay in the air so long…

• Worksheets with cues on paper allow the child extended processing time during grapheme – phoneme association skill development in a manner similar to the AM

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Setting up a Worksheet

• As with the AM, initial worksheets should focus on individual phonemes .

• As more phonemes are learned, the child should have to discriminate among those that look similar. – For example the CS representations of /b/ and /n/

have the same hand shape, so the child must attend to the lips. /b/ and /m/ look alike on the lips and the hand must be carefully evaluated.

(/b/) (/m/) (/n/)

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Sample worksheet

• a ______ ______ ______

• b ______ ______ ______

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Practice is critical

• As with the AM, practice discriminating the phonemes and associating them with the relevant letters is particularly important if the child who is not a skilled cuer or has a language delay.

• It also helps with the development of automaticity, necessary for fluent decoding.

• As with the AM, the child should practice using work sheets, reading, “oral” drills (cue/say), etc. until the decision of which letter is associated with a particular phoneme is automatic.

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Worksheets to reading• As with the AM, once the child learns letter-sound

associations, words using them can be presented.

– If first set is “n”, “t”, and “a”, the child should be able to read and write “tan”, “ant”, “an”, “at” and “nat”.

– These can initially be presented as isolated cues, rather than cues representing running speech (CV pairing).

• That is introduced once the child is skilled in automatically decoding letter-sound relationships.

– For PLD children inclusion of a picture to provide meaning for the word offers vocabulary development as well as reading and language skill development.

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Letters to words

– h ______ _______

– b ______ _______ – Note that even letters that have not been introduced

can be included with the relevant grapheme provided for the child.

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Isolated Cues to running Cues

• Words sounded out by isolated phonemes paired with the CS representations of those words provided in isolation are shown in running cues (consonant-vowel pairs).

• Thus, the child would learn that:

c a t = cat

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Cueing on Paper

• Provide print, cues and pictures to optimize language development.

• Sight words should be presented as running cues

• do • Initially present decodable words both ways

h a t = hat

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Other benefits…

• Vocabulary learned through digital cues is more likely to be accurately recognized during face-to-face communication.

• Vocabulary presented via digital cues/print/ pictures is more likely to be retrieved with less effort.

• When words are presented in categorical sets, this provides organization to support comprehension, retrieval and memory.

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Application of Cued Speech to development of phonological awareness in deaf children.

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Phonological awareness• Research indicates that phonological awareness

is important for fluent reading.– Deaf children typically have difficulty with

phonemic awareness– The visual support from Cued Speech can clarify

the ambiguous/absent auditory signal

• Phonemic awareness activities that typically use speech can be performed using Cued Speech. – The only adaptation is for the teacher/therapist

(and, preferably, the child as well) to Cue.– This automatically makes the phonemic information

clear to the child.

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Phonological awareness activities• These are oral tasks, based on how words sound• They are readily Cued and can be done as

worksheets using digital pictures.– phoneme deletion (“say sit without the /t/ sound.”)– word to word matching (“do sit and sun start with the same

sound?”) – blending (“what word would you have if you put these sounds

together: /s/, /i/, /t/?”)– sound isolation (“what is the first sound in sit?”)– phoneme counting (“how many sounds are there in the word

sit?”)– deleting phonemes (“what sound is in sit that is not in it?”)– odd word out (“what word starts with a different sound: sit see,

hit, sun?”)– sound to word matching(“is there a /n/ in sun?”).

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Reading

• Children with language delays may generally have difficulty learning to read.

• The language development program described above teaches reading simultaneously with language.

• Once basic vocabulary and decoding automaticity is developed, sentences and grammar can be presented.– Use picture comprehension tasks with sentences

with print &/or Cues.

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Advantages of Cued Speech

• When decoding, the child must match the phonemes decoded from text to the internal phonological representation of the word.

• If they don’t have phonemic representation of the word associated with meaning, they have no model with which to match the word. – Even if they know that /k/, /a/, /t/ represents /kat/, they

cannot access meaning unless they have seen the phonemic model /kat/ paired with meaning enough times to associate it with the small furry animal.

– CS allows this exposure in multiple formats.

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Teaching the basic rules of regular sound-letter relationships

• Separating the grapheme from the phoneme is particularly important for – sounds that have multiple graphemic representations (/ew/,

/ue/, /oo/) – graphemes that have multiple phonemic representations

(such as “c”).

• With a hearing child, we can say “c” as in “cake” as opposed to “c” as in “city” or “race”. – Fingerspelled or printed, they all look like the same “c”.

• Clarified via CS, the differences are unambiguous.• Children phonemic decoding skills can “sound out”

unfamiliar words regardless of their hearing status.

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Compatibility with phonemic reading programs

• Because Cued Speech provides unabmiguous access to the phonemes of the language, it is readily compatible with standard phonics based reading programs (e.g., Phonographix, Lindamood Bell) in addition to the AM

• Many of these programs present pictures the child can use to identify the phonemes (similar to AM symbols). – Cued Speech offers similar visual representation, with

increased clarity.

• The phonemes being studied during the reading program can be presented either through the air (cueing to the child and the child cueing) or on paper.

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Literacy• The child can match decoded words to her

internal lexicon of words experienced through receptive cueing (face-to-face or on paper).– Word recognition is possible vs learn each word in

print and associate it with its concept and/or sign.• Knowledge of English grammar and broad

vocabulary enable the child to use context to figure out the meaning of truly unfamiliar words.– This minimizes the load on working memory, leaving

more resources available for comprehension and processing into memory, improving verbal memory.

• Verbal sequential processing skills are enhanced.– These skills are similar to hearing subjects in Cuers,

but are weak in typical Signers.

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Use of expressive Cueing to monitor expressive reading in children with limited speech intelligibility

• Children with speech/language delays may have speech that is of limited intelligibility.

• This makes it difficult to know if their oral reading is inaccurate or if they are simply unable to produce the sounds despite accurate internal decoding.

• If the child cues expressively, monitors can check decoding of text through cued "oral" reading exercises.– The focus in this case should be on what the child cues rather

than the sounds produced.– This provides tactile/kinesthetic feedback to support decoding.

• Intelligible speech is not necessary to determine if decoding is accurate.

• Thus, errors in decoding can be corrected and accurate decoding reinforced regardless of speech skills.

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Take home message

• Every child can develop language.

• CS may work best for many children with additional language challenges.

• You need to work with their strengths and find ways to remediate and accommodate their weaknesses.

• Accuracy is more important than speed.

• JUST CUE IT!!!