The Hand Cue

The Hand Cue is one of the most hotly debated and contentious aspects of Auditory-Verbal Therapy.  What is the Hand Cue?

The Hand Cue consists of:

• the therapist, parent or caregiver covering his/her mouth briefly, when the child is looking directly at the adult’s face. This encourages listening rather than lip-reading. When the child is playfully engaged and not looking, the Hand Cue is unnecessary.

• the adult moving his/her hand toward the child, in a nurturing way, as a prompt for vocal imitation or as a signal for turn taking; and/or

• the adult talking through a stuffed animal, a toy, a picture, or a book, placed in front of the speaker’s mouth.

The Hand Cue signals the child to listen intently, and is used to assist the child to integrate all five senses. The Hand Cue should be used only when necessary because some of its uses distort, smear or eliminate the sound arriving at the microphone. As children come to rely on hearing, the use of the Hand Cue is reduced (Estabrooks, 1994). Once the child has “integrated hearing into his or her personality” (Pollack 1985), the Hand Cue is rarely used. (The Hear and Say Centre)

Common objections to the Hand Cue include:

• It distorts the speech signal.  Since a hand is not acoustically transparent, it changes the nature of the sound arriving at the child’s microphone.  Though this makes sense logically, I have not seen any published data on how the sound is changed — is the difference significant?  And, if so, does that matter?  For example, would a distorted sound (frequency alteration) change the child’s ability to correctly produce the phoneme, or would a slight lessening of the intensity (volume) of the signal actually make the training condition more difficult and thus better prepare the child for difficult listening environments?  I don’t own my own speech spectrometer (birthday list, anyone?), so I do not know.

• It is pragmatically inappropriate.  It’s just not a natural social interaction to cover your mouth or put your hand to another’s mouth to encourage him to talk.  This is, in my opinion, a valid objection.  Given the ability of AVT graduates to attain appropriate pragmatic skills through incidental learning and the 99.99% of their lives that they are NOT in a therapy situation where the Hand Cue is used, I doubt that this temporary pragmatic inappropriateness has any long-lasting effects, but the objection stands.

One of the biggest problems with the Hand Cue is when it is misused or overused.  Quite simply, if the child’s not looking, why are you covering?  (For example, in the photo above, the child IS looking at the therapist’s mouth, and she is using the Hand Cue correctly.)  Children who have integrated hearing into their personalities are often highly capable of focusing on a toy while listening to the therapist or parent speaking.  In that case, using the Hand Cue is overkill.  It often helps to tape your therapy sessions and watch for this bad habit in yourself — it’s a classic mistake caused by a well-intentioned desire to help the child listen, listen, listen!

At Warren Estabrooks’s seminar that I attended earlier this month, he discussed a new alternative to the Hand Cue — Visual Distraction Techniques (VDTs).  Instead of covering your mouth when you want to encourage the child to obtain information through listening, provide a visual distraction, like pointing to the object being discussed or holding the toy away from your face.  This helps to focus the attention on the object, not your mouth and provides the child with an unimpeded auditory signal while still encouraging them to listen, not look, to understand.

Okay, this is not so life-altering.  As I said before, there are usually very few true instances where the Hand Cue is needed, so in those moments, using a VDT instead should be an easy change to make.  So, why is it a big deal for those in the AVT world to wrap their heads around?  Well, I’ve given it a little thought, so please bear with me as I play amateur anthropologist for a second and share with you my theory:  Auditory-Verbal therapy is essentially a-symbolic.  There are no special tools or toys or i-love-you hand symbol mugs or embodied markers that designate a person as “AVT.”  In fact, the whole goal of the approach is that children with hearing loss should be given the skills necessary to leave and become whoever they want to be.  If we do our job, the children leave us.  For therapists raised  in the great traditions of the founders of Auditory-Verbal Therapy, there’s something very powerful about that gesture, something that says, “I am an Auditory-Verbal Therapist.”  It’s a little thing that cannot be underestimated… but does that make it right?  Our desires as therapists to appear “therapeutic” should never outweigh doing what is best for the child.  Ultimately, it’s just not about us.