Understanding spoken , through both listening and watching. The role of lip-reading and how Cued (CS) might help

By Anne Worsfold, parent of two deaf sons (now adults) and Director of the Association UK, a national charity run by parent and professional users of CS.

As hearing people, especially when we are parents of deaf children, we tend to think of lip-reading as something particularly important for deaf people. And once we add cochlear implants into the mix, the temptation is to think that for implanted deaf children, as for hearing children, lip-reading is a handy addition when background noise is extra bothersome. I was astonished to discover that hearing babies watch lips as part of the development of their language1 and that if the speaker is using a language babies are not familiar with (the research looked at Spanish) they pay attention for even longer.1

Even more amazing is the fact that adults can’t help ‘lip-reading’ others, as demonstrated by the fascinating (but unimaginatively named) McGurk Effect2. If you are not familiar with it, it’s a phenomenon where the sound a person ‘hears’ changes to match the lip-pattern of the sound. Do take a look at a BBC item at: https://www.youtube.com/watch?v=G-lN8vWm3m0. It’s a compelling demonstration of how we can’t intellectually ‘over-ride’ the visual speech information we see.

This implies that watching lips is an integral part of language learning for all, and that as adults we can’t ignore the language information on the lips. In other words, speech is multi-sensory. But how important is this for implanted children? Some more research would suggest it has high importance:

‘The earlier a child is implanted the more likely they are to be able to follow speech without lip-reading two years post implant’3. but ‘even children implanted before 18 months can take several years to reach a level where they can follow a simple conversation with a familiar person in a quiet environment without lip-reading’4. and ‘Some causes of deafness lead to fewer benefits of cochlear implantation in terms of using auditory cues. For example: Hypoplasia of the auditory nerve can compromise its stimulation by electrical impulses from a and children with this condition show less benefit from implantation in terms of auditory development.’5

Additionally, on a practical level, we all know that no matter how well a deaf child hears with an implant in perfect situations, situations are not always perfect, for example: in background noise, at distance and the inevitable times when the implant is simply not on, or not working (bed-times, illnesses, battery dead etc.). On these occasions lip-reading may fill a few of the gaps. But, unfortunately, it won’t fill all the gaps because a large part of lip-reading is guesswork.

Many people think ‘lip-reading’ is very poorly named. The name implies that it is possible to learn to read lips in the same way as learning to read a book, but it’s much more complicated because every sound on the lips looks like at least one other sound, and some sounds are articulated inside the mouth and are completely invisible. ‘Lip-reading’ therefore involves one educated guess after another so much so that only around 35% can be accurately lip-read.6 Also, if a word is visually ambiguous it is harder to learn and to later read. For example ‘mat’, ‘pat’ or ‘bat’ all look the same on the lips, and a deaf child may respond correctly to each word (because the context is clearly different) but they may be surprised to find that they have three different spellings.

The Rose Report7, which looked at teaching reading, identified two skills needed when learning to read: 1.) a knowledge of the language and 2.) a knowledge of sounds.

Deaf children who need to lip-read are doubly disadvantaged when learning to read because it’s harder for them to learn words (they have poor language), and they have less knowledge of the sounds () in each word. So it’s not surprising that research in 2014, looking at 79 oral / aural deaf children (aged 10 - 11) found that 71% were ‘poor’ or ‘extremely poor’ readers (set against 2001 standards), and a ‘substantial group’ of the 29% of ‘average’ readers were flagged as being at risk of developing reading problems later because of poor language8.

So potentially, a system that increases the power of lip-reading to identify every ‘sound’ of speech will help the development of both language and literacy.

CS will do that. It is a visual representation of ‘spoken’ , and it works by supplementing the lip-patterns of speech. There are just eight handshapes, which clarify the consonants, and four positions which clarify the sounds. With CS, lip-reading accuracy rises to 96%6. CS is used by the adults around the deaf child so that they can see an unambiguous visual version of English. It can be used both to accompany what the child hears through an implant or instead of ‘hearing’ when the implant is not being worn. It takes, on average, about 20 hours for adults to learn to cue, and several months practice to be able to cue at the speed of speech.

There’s a large and growing body of research showing the benefits of CS. Here are just a few:

Literacy - International research demonstrates that deaf children brought up with Cued Speech achieve reading scores equivalent to hearing children9&10 and that cueing deaf children acquire phonological abilities better than non-cueing deaf children and comparable to hearing peers9. A recent English case-study looking at the perception of phonemes in regular non-words found 50% accuracy in spelling non-words (e.g. ‘drump’) when listening and lip-reading, and 100% accuracy once Cued Speech was added11.

Lip-reading - ‘Adults raised on CS (from at least 3 years of age) are better at speechreading without cues than deaf adults who have never been cued to’12.

I started using CS with my deaf children nearly 30 years ago and I’ve been involved with the Cued Speech Association UK for 20 years. In that time, the use of implants has transformed the outcomes of many deaf children, and my own children (who weren’t implanted) have entirely reached their potential with CS. It’s disappointing that implanted children still do less well than hearing children – some significantly so. If you feel that your son or daughter would benefit from visual access to language, then the evidence, as well as parent’s feedback, would indicate that CS would be a valuable addition.

Using CS is not an option which excludes others. It can be used to support listening and also works very well bilingually with British (BSL). BSL is, of course, an entirely different language to English and gives access to the BSL-using community. In contrast, CS is just English – but a visual mode of English. It is YOUR speech made visible, and it gives additional access to English for occasions when listening, for whatever reason, permanently or temporarily, is inadequate for your child to fully understand speech. A tiny minority of deaf children use CS to communicate but for most it gives the additional language information which enables them to communicate through speech alone.

The Cued Speech Association UK can advise about CS use, and can arrange for family training (often in your own living room, at a time to suit, through Skype). Learning CS is a bit like learning to type when you can already write long-hand – and nothing like learning a new language. At the moment our charity has funds to offer tree training to families for whom the cost could be a barrier, and the first Skype session is free.

I’ll leave the penultimate words to a professional: Dr Ruth Campbell, who has held faculty posts at the University of Oxford and the University of London, and co-founded the Deafness, Cognition, and Language Centre at University College London in 2005.

‘…….[research] has shown conclusively that children exposed consistently to Cued Speech gained and maintained a headstart over deaf children of similar intelligence and skill who did not have Cued Speech. Those who started using Cued Speech before school were even more likely to forge ahead, often with literacy levels and styles indistinguishable from hearing children…….’ ‘The importance of Cued Speech is that it opens up the world of spoken language to the deaf child in a clear and simple way, from the outset.’13

And I’ll leave the last words to a parent whose son was considered a cochlear implant ‘failure’ but who has benefitted from CS input and is now thriving in a mainstream school. His reading age and vocabulary level are both two years ahead of hearing peers, and he has intelligible speech. He is now no-longer always reliant on visual language input but can understand some speech by listening. His mother writes:

‘The huge and unexpected improvement in his listening skills over recent years challenges the assumption that developing and supporting listening depends on prioritising auditory over visual input. Our experience suggests that for children whose aided hearing is very poor, early, continuing and full acquisition of English visually through CS could be a key to developing good listening and oral skills later……..The discovery of CS and what it could do for our son and for us as a family was truly and profoundly life changing, and continues to be thirteen years down the line.’

For the whole of the parent’s article go to: http://www.cuedspeech.co.uk/uploads/documents/Information%20Sheets/Case%20Studies/2016%2 0Case%20Studies/Case1.pdf

For more information about CS use or to find out how to learn, contact the Cued Speech Association UK at: [email protected] 01803 712853 Web: www.cuedspeech.co.uk

With thanks to Dr Rachel Rees, MSc Speech and Language Sciences Programme Tutor, University College London, Division of Psychology and Language Sciences.

Research refs: 1. David J. Lewkowicz1 and Amy M. Hansen-Tift Infants deploy selective attention to the mouth of a talking face when learning speech Proceedings of the National Academy of Sciences January 31, 2012 vol. 109 no. 5 2. McGurk H., MacDonald J. (1976). Hearing lips and seeing voices. Nature 264 (5588): 746–8. 3. O’Neill, C., O’Donoghue, G. M., Archbold, S. M., Nikolopoulos, T. P., & Sach, T. (2002). Variations in Gains in Auditory Performance from Pediatric Cochlear Implantation. Otology & Neurotology January 2002, 23(1), 44–48. 4. De Raeve, L. (2010). A Longitudinal Study on Auditory Perception and Speech Intelligibility in Deaf Children Implanted Younger Than 18 Months in Comparison to Those Implanted at Later Ages. Otology & Neurotology, 31(8), 1261–1267. http://doi.org/10.1097/MAO.0b013e3181f1cde3 5. Valero, J., Blaser, S., Papsin, B. C., James, A. L., & Gordon, K. A. (2012). Electrophysiologic and Behavioral Outcomes of Cochlear Implantation in Children With Auditory Nerve Hypoplasia. Ear and Hearing, 33(1), 3–18. http://doi.org/10.1097/AUD.0b013e3182263460 6. Ling, D, & Nicholls, G. (1982). Cued Speech and the Reception of Spoken Language, Journal of Speech and Hearing Research, 25, p262-269 7. The Rose Report, (2006) an Independent Review of the Teaching of Early Reading, published by the department for Education and Skills. 8. Herman, R., Roy, P., & Kyle, F. (2014) Reading, and Oral Deaf Children : From Research to Practice. London, UK: Nuffield Foundation; City University London. 9. Wandel, J.E. (1989) Use of Internal Speech in Reading by Hearing and Hearing Impaired Students in Oral, Total Communication, and Cued Speech Programs. (Unpublished Doctoral Dissertation). Teacher’s College, Columbia University, New York. 10. Colin, S., Leybaert, J., Ecalle, J., & Magnan, A. (2013). The development of word recognition, sentence comprehension, word spelling and vocabulary in children with deafness: A longitudinal study. Journal of Research in Disabilities, 34, p1781-1793. 11. Rees, R., & Bladel, J. (2013). Effects of English Cued Speech on , phonological awareness and literacy: A case study of a 9-year-old deaf boy using a cochlear implant. Deafness & Education International, 15, p182-200. 12. Aparicio, M., Peigneux, P., Charlier, B., Neyrat, C. & Leybaert, J. (2012). Early experience of Cued Speech enhances speechreading performance in deaf. Scandinavian Journal of Psychology 53, 41–46. 13. Cued Speech and Cued Language for Deaf and Hard of Hearing Children edited by Carol J. LaSasso, (Ph.D. Professor Hearing Speech and Language Sciences, Gallaudet University, Washington D.C.) Kelly Lamar Crain (Ph.D. Assistant Professor of University of South Florida) and Jacqueline Leybaert (Professor of Psychology, Université Libre de Bruxelles, Belgium.