Communication Options

For Children with Severe-to-Profound Hearing Loss

[Adapted by Karen L. Anderson, Audiology Consultant, Florida EHDI Project (January, 2002) from K. Biernath, MD., (1999), Center for Disease Control and Beginnings website (2000)]

Communication features can be combined into different communication options, or methods. There are many philosophical differences about the superiority of one communication option over another. The bottom line is this – the best communication option for your child is the one that caregivers are willing and able to use comfortably and consistently and that meets the communication development needs of your child. No specific method will result in successful learning outcomes if caregivers and family members do not surround and immerse the child in whatever communication features comprise the method.

American Sign Language (Bilingual)

Bilingual/Biculturalism is designed to give children with hearing loss fluency in two languages – American Sign Language (ASL) and English or the family’s native language. It also seeks to provide children with knowledge about and acceptance into two cultures – deaf and hearing. American Sign Language, or ASL, is the language of the American Deaf Community.  This complete visual-spatial language does not require the use of spoken words or sounds. Instead it manipulates space, movement and signs to efficiently and completely present information. All language universals including humor, emotion, philosophical ideas and abstract concepts can be fully conveyed in American Sign Language. Interest in the Bi/Bi communication option stemmed from the recognition of the age-appropriate language levels typical of deaf children of Deaf parents.

In the Bilingual/Bicultural communication option, also called Bi/Bi, ASL is usually taught as the child’s primary or first language. English or the family’s native language is taught as the child’s second language with emphasis on the written form of the language. This option consists of two main communication features: ASL and the written form (sometimes the spoken form) of a language, such as English, and is one of the newer education approaches appearing as a recent trend of education for children with hearing loss.

Total Communication

Total communication is an approach of communication and education for children with hearing loss that uses a combination of communication options, including oral and manual techniques. In this option, children and families are encouraged to use a spectrum of communication techniques. Manually Coded English (MCE), speech reading, speech and use of residual hearing, cued speech, natural gestures and body language are all encouraged. Personal amplification (hearing aids, FM systems, cochlear implants) are considered important in most total communication programs as children are encouraged to make maximum use of their residual hearing. Initially, ASL was not included in total communication programs, as the importance of learning English as the first language was stressed. In recent years, however, as ASL has gained more respect in educational settings, this language is being introduced into more total communication programs as a second language.

MCE is a system of signs (many of which are borrowed from ASL) presented in word order that are based on words as opposed to conceptual meaning. MCE is a visible representation of spoken English and, therefore, it is not a language. Speech reading, a technique by which a person attempts to understand speech by watching the speaker’s mouth and facial expressions, is encouraged in most Total Communication programs. Cued speech is a visual code based on the sounds of words that can be used in TC programs to enhance speech reading or literacy development.

Cued Speech

Cued Speech is a system of eight hand shapes that represent groups of consonant sounds and four hand placements that represent groups of vowel sounds used in combination with the natural lip movements of the speaker.  The hand shapes and placements are grouped in sets that do not look alike on the lips, to make speech visible and clear to the cue-reader.

R. Orin Cornett, Ph.D. developed the system in 1965 to make it possible for deaf children to acquire naturally, in their homes, the language they will eventually be expected to read and write.  Cued Speech has been adapted for use in more than 50 spoken languages. Cued Speech is not a language; it conveys the language, including the vocabulary, syntax, and grammar, that is being spoken. Parents of young deaf children are encouraged to use voice when they cue, to take advantage of any residual hearing their children have; however, translators who cue for students in the classroom, do not use voice.  The system has been used successfully with children who have no residual hearing.

Cued Speech has also been called Visual Phonics because of the visual representation of all of the phonetic elements of speech. Cued Speech is used as a tool to assist with speech reading spoken languages. This system is believed to encourage the development of reading or literacy through encouraging a child to learn the spoken language as his or her first language. Thus, Cued Speech consists of four main communication features: Cued Speech hand shapes, speech reading, speech, and the use of residual hearing. Use of personal amplification such as hearing aids, FM systems, or cochlear implants are also important with this approach.


The Auditory-Oral option emphasizes maximum use of residual hearing through technology (hearing aids, FM systems, cochlear implants) and auditory training to develop the speech and communication skills necessary for full involvement in the hearing society. The focus of this option is to use the auditory channel to acquire speech and oral language and is based on the assumption that most children with hearing loss can be taught to listen and speak with early intervention and consistent training to develop their hearing potential.

The Auditory-Oral option includes the use of speech reading and natural gestures. Manual forms of communication, such as Manually Coded English and American Sign Language, are not encouraged. Natural gestures and body language are accepted. Thus, the Auditory-Oral option consists of four main communication features: speech, audition, speech reading, and gestures or body language.

The Auditory-Oral option relies on the user to have amplified residual hearing of a sufficient enough degree to allow the development of an auditory feedback loop (perceiving one’s own voice which aids in monitoring speech production). The greater the amount of residual hearing an individual has the better the chance for success with the Auditory-Oral option. A very important key to the potential success of Auditory-Oral option is optimal amplification of residual hearing or use of a cochlear implant. Thus, a strong working relationship with an audiologist is vital.

Speech reading is an important communication feature in the Auditory-Oral option. In the best environment (good lighting, etc.) only approximately 40% of the English sounds are visible. Much of the meaning of conversation is deduced through context and guessing based on world knowledge and conceptual and syntactic language proficiency. The ability to speech read has been shown to be unrelated to intelligence or motivation. Due to shifting dynamics of conversation between speakers or in a group discussion classroom situation, it can be very difficult to keep up with the conversation, even for a very talented speech reader.


The primary objective of the Auditory-Verbal option is to “equip the child to integrate into classrooms and society at large.” This communication option uses the child’s residual hearing, hearing technology, and teaching strategies to encourage children to develop listening skills to enable them to understand spoken language through amplified hearing or cochlear implants in order to communicate through speech. The emphasis is on development of speech and language through auditory pathways, or hearing. Speech reading, signing, and natural gestures and body language are discouraged. Thus, the Auditory-Verbal option consists mainly of two communication features: audition and speech, with the use of residual hearing with technology and amplification being a vital component.

In the Auditory-Verbal option, the child is expected to rely on audition alone during specific teaching times. One to one teaching with a therapist trained in the Auditory-Verbal options with parents present, and then daily one to one instruction time with the parents, is vital. Use of the hand cues during formal teaching times have been used in the Auditory-Verbal option. These hand cues may consist of one or more of the following techniques: the therapist, parent, or caregiver covering his/her mouth when the child is looking directly at the adult’s face; the adult moving his or her hand toward the child’s mouth in a non-threatening and nurturing way as a prompt for vocal imitation or as a signal for turn taking; and the adult “talking through” a stuffed animal or other toy placed in front of the speaker’s mouth.

Currently, emphasis is on more subtle signals such as encouraging the child to look at something other than the speaker’s mouth when speaking and naturally covering the mouth when speaking. It is not expected that the parents or caregivers would cover their mouths during all daily living activities outside of the direct instruction time