Cueing with Children with Disabilities Affecting Language Development

1
Cueing with Children with Disabilities Affecting
Language Development

• Donna A. Morere, Ph.D.
• Gallaudet University
• Donna.Morere_at_gallaudet.edu
• Donna.Morere_at_verizon.net
• NCSA 7/22/06
• ASHA CEU code SC-02

2
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

3
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.

4
ADHD

• Affects development of
• Language
• Social skills
• Behavior emotional and adaptive
• Academic skills.
• Commonly recognized symptoms include
• Inattention
• Distractibility
• Impulsivity
• Over activity

5
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
  childs ability to develop language and other
  skills regardless of attention.

6
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

7
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.

8
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

9
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 dont 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

10
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

11
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.

12
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
  doesnt get it, THEN, re-phase.
  
• Use the static strategies discussed later

13
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

14
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

15
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 doesnt help with peer relations.
• Difficulty with fine and complex motor skills
• Affects expressive signing, cueing and writing.

16
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.

17
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.

18
NLD Social Skills

• These children cant 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.

20
NLD and Cued Speech

• 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

21
NLD and Cued Speech

• 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.

22
NLD and Cued Speech

• 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.

23
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.

24
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.

25
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
  childs 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

• Those with more severe disorders often appear
  confused or completely lost.
  
• He may not follow classroom rules or
  instructions.
  
• Due to lack of understanding of what is required
  rather than willful misconduct.
  
• He may nod or otherwise seem to indicate
  understanding or demonstrate partial
  understanding of the rules, but may miss key
  elements, such as not.

29
Presentation of the Deaf Child with PLD

• She depends on non-language visual cues for
  information.
  
• Attempts at expressive communication
• are inadequate
• incorporate more visual-gestural communication
  than ASL or CS
  
• may include acting scenes out and drawing or
  other use of pictures.

30
Presentation of the Deaf Child with PLD

• He may seem to understand things one day and have
  lost them the next.
  
• Those with developing language skills or a milder
  form of the disorder may
  
• seem slow to respond or
• have delayed comprehension.
• may have difficulty learning to read when
  compared to deaf peers from similar backgrounds.

31
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.

32
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.

33
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.

34
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.

35
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.

36
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
  doesnt 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)

37
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 dont
  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!

38
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 cant provide it for themselves.
  
• They need concrete visual cues to tell them when
  things are about to change and what is expected
  of them.

40
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.

41
Developing linguistic organization

• Kids develop knowledge based on exposure and
  correction.
  
• Pictures and digital cues can be added.
• Charts with categories can be made.

Great Dane
Chihuahua
Labrador
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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.

43
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.

44
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.

45
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.

46
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

47
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.

48
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.

49
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

50
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.

51
Sample worksheet

• a ______ ______
  ______
  
• b ______ ______
  ______

52
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.

53
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.

55
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

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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

57
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.

58
Application of Cued Speech to development of
phonological awareness in deaf children.
59
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.

60
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?).

61
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.

62
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 dont 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.

63
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.

64
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.

65
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.

66
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.

67
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!!!