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@gallaudet.edu Donna.Morere@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 child’s 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 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

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 doesn’t 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 doesn’t 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 twohave 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 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.

19. 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 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.

26. 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.

27. 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.

28. Presentation of the Deaf Childwith 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 Childwith 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 Childwith 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 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)

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 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!

38. /ue/ /e/ /oo/ /i/ /uh/ /p/ /b/ /m/ /f/ /v/ Digital Cues: phonemes on paper

39. 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.

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. Kids develop knowledge based on exposure and correction. Pictures and digital cues can be added. Charts with categories can be made. Developing linguistic organization Great Dane Labrador Chihuahua

42. 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.