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The Hand Cue

January 29th, 2011 by | Tags: , , , | 8 Comments »

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.

Written by

Elizabeth Rosenzweig MS CCC-SLP LSLS Cert. AVT is a Listening and Spoken Language Specialist Certified Auditory Verbal Therapist. She provides auditory verbal therapy, aural rehabilitation, IEP advocacy, consultation, and LSLS mentoring for clients around the world via teletherapy. You can learn more about Elizabeth's services on her Website or Facebook.



January 30, 2011 at 1:20 am

At John Tracy they taught us to angle the hand more at 45 degrees than 90 to distort the signal less. I do find it has its place but as you said, eventually it becomes unnecessary.


January 30, 2011 at 1:29 am

Very interesting, Monica. That adds another layer to the experiment. What is the optimum hand angle for minimum signal distortion? Now, to find out where I can get my hands on a speech spectrometer!

January 31, 2011 at 2:30 am

As always, your editorial is perfectly clear and very pragmatic. Since our foundation has mostly french readers, from time to time I’ll plunder some tidbits and quote you as our source, as well as include your website references for our english readers. Keep up the good work for all the parents who strive to make their deaf children autonomous!


January 31, 2011 at 11:44 am

Merci beaucoup, Antoine! You are welcome to share this information with your readers. I just ask that you cite the source and provide a link back to the original. I hope it is of benefit to you and the families you serve!

February 2, 2011 at 9:03 pm

Another method (especially if you are sitting next to the child) is to simply lean behind them slightly when you speak. This puts the signal closer to the microphone, and they can’t see your mouth. We rarely use the hand cue anymore, except for when doing the Lings (Nolan can’t hear the /s/ sound with his hearing aids at a distance of more than 3 feet, but if he can see my mouth, he’ll get it right every time)!

Our TOD takes an embroidery hoop and uses the screen you see in speakers (acoustically transparent) and uses it for Lings and other work: this way the softer sounds like /f/ and /s/ don’t get blocked, but the visual is still removed.


February 13, 2011 at 1:55 am


February 19, 2011 at 9:33 am

Are the main reasons it’s one of the “hotly debated and contentious aspects of Auditory-Verbal Therapy” the two that you mentioned?

As a deaf adult who had therapy of this type as a child, I’ll mention a third, personal, objection: this causes frustration and emotional distress to the child when you intentionally interfere with her ability to understand your communication.


February 19, 2011 at 10:56 pm

Leah, thank you for sharing those tips. Those are both other good options to encourage audition over vision.

Mina, I’m so sorry to hear that your experience was frustrating. When used properly, the Hand Cue, or any other kind of visual distraction technique (VDT), should be done in a nurturing manner. I’ve stated in other articles on this site that when a child has something emotionally charged or important to say, that is not the time for therapy techniques. Focusing on hearing over seeing is a tool to grow the child’s auditory brain as part of a larger program of Auditory-Verbal Therapy that focuses on listening, speech, communication, cognition, AND the social-emotional well-being of the child and family.