Double-decision lexical tasks in thought-disordered schizophrenic patients: A path towards cognitive remediation?

Brain and Language 95 (2005) 395–401 www.elsevier.com/locate/b&l

Double-decision lexical tasks in thought-disordered schizophrenic patients: A path towards cognitive remediation? Chrystel Besche-Richard a,¤, Christine Passerieux b, Marie-Christine Hardy-Baylé b a

b

Université de Bourgogne, Dijon, France Centre Hospitalier de Versailles, Le Chesnay, France Accepted 10 March 2005 Available online 20 April 2005

Abstract It has been shown that schizophrenics have certain diYculties in the processing of semantic context. These diYculties have usually been evaluated using lexical decision tasks with semantic priming. In this study, we chose to examine the idea of an abnormality in the early stages of semantic context processing in thought-disordered schizophrenics using two double lexical decision tasks: one with a high (25%) and one with a low (15%) proportion of related words to assess the participants’ competency in controlled and possibly also more automatic context processing. The results obtained in 40 control participants and 40 schizophrenic patients revealed no signiWcant diVerences in the amplitude of semantic priming between the two groups. These results suggest that, in the disorganized schizophrenic subjects evaluated in this study, the context processing processes mobilized by the employed tasks were unimpaired.  2005 Elsevier Inc. All rights reserved. Keywords: Schizophrenia; Semantic priming; Thought disorders; Proportion of related words

1. Introduction Context processing deWcits in schizophrenic patients have been the object of frequent studies over the last 10 years (Cohen, Barch, Carter, & Servan-Schreiber, 1999; Cohen & Servan-Schreiber, 1992; Goldberg et al., 1998; Hardy-Baylé, Sarfati, & Passerieux, 2003; Spitzer, 1997). These cognitive anomalies have been particularly well studied using lexical decision tasks with semantic priming. The results obtained from schizophrenia patients have been somewhat mixed. The lexical decision task (LDT) evaluates context processing on-line, and the results can be interpreted in terms of attentional theories (Posner & Snyder, 1975) distinguishing between automatic and controlled processes. According to these studies, automatic processing gives rise to automatic spreading activation of words *

Corresponding author. Fax: +33 3 80 39 39 95. E-mail address: [email protected] (C. Besche-Richard).

0093-934X/$ - see front matter  2005 Elsevier Inc. All rights reserved. doi:10.1016/j.bandl.2005.03.003

that are related in semantic memory and occurs rapidly without any intention or awareness on the part of the subject (Meyer & Schvaneveldt, 1971). In contrast, the controlled processes require cognitive eVort and attention, are performed slowly, and inhibit unrelated information in the semantic lexicon. The literature describes two types of controlled processes frequently observed in LDT: an expectancy generation strategy (subjects read the prime and generate the target) (Neely, 1976, 1977) and a postlexical checking strategy in which subjects assess the semantic relation between the prime and target before making their decision on the target (de Groot, 1984; de Groot, Thomassen, & Hudson, 1986; Lorch, Balota, & Stamm, 1986; Shelton & Martin, 1992). In any case, and whatever the type of processes involved (automatic or controlled), it has been observed that the time taken to recognize a target word preceded by a semantically unrelated prime is longer than the time taken to recognize a target word preceded by a related prime (semantic priming).

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Several experimental variables can be manipulated to identify the nature of the cognitive processes involved in a lexical decision task. First, the Stimulus Onset-Asynchrony (SOA), i.e., the temporal interval between the prime and the target stimuli. Second, the degree of structuring of the verbal material, particularly the proportion of related words inXuences the eVectiveness of the two controlled processes but has no impact on automatic spreading. Two principal hypotheses have been proposed concerning the types of abnormalities observed in schizophrenic patients when performing an LDT (for a review, see Hardy-Baylé et al., 2003; Minzenberg, Ober, & Vinogradov, 2002). First, studies have concluded that thought-disordered schizophrenics exhibit hyperactivation of associations in the mental lexicon (presence of hyperpriming) in line with the hypothesis of abnormalities in automatic processes (Kwapil, Hegley, Chapman, & Chapman, 1990; Manschreck et al., 1988; Moritz, Woodward, Kuppers, Lausen, & Schickel, 2002; Spitzer, 1993; Spitzer, Braun, Hermle, & Maier, 1993; Spitzer, Braun, Maier, Hermle, & Maher, 1993; Spitzer et al., 1994; Weisbrod, Maier, Harig, Himmelsbach, & Spitzer, 1998). Second, various studies have shown a reduction or an absence of semantic priming in schizophrenic subjects and these observations have been interpreted in terms of a controlled context processing deWcit, and more speciWcally in terms of disorders of the postlexical checking strategy in these patients (Besche et al., 1997; Ober, Vinogradov, & Shenaut, 1995, 1997; Passerieux, Hardy-Baylé, & Widlöcher, 1995; Passerieux et al., 1997; Vinogradov, Ober, & Shenaut, 1992). More speciWcally, this abnormality has been observed in thought-disordered schizophrenics (Besche et al., 1997; Henik, Priel, & Umansky, 1992; Henik, Nissinov, Priel, & Umansky, 1995; Passerieux et al., 1997). Finally, some studies have indicated the presence of a normal semantic priming eVect in schizophrenic patients (Chapin, Vann, Lycaki, Josef, & MeyendorV, 1989; Chapin, McCown, Vann, Kenney, & Youssef, 1992), including thought-disordered patients (Blum & Freides, 1995). A rereading of the literature on semantic priming in schizophrenic patients enables us to make certain suggestions that may explain these results more comprehensively. First, we can consider the clinical types of schizophrenic patients: disturbances in semantic priming seem to be associated with the presence of thought disorders in schizophrenic subjects (Aloia et al., 1998; Besche et al., 1997; Henik et al., 1992, 1995; Kwapil et al., 1990; Manschreck et al., 1988; Moritz et al., 2002; Passerieux et al., 1995, 1997; Spitzer, Braun, Maier, et al., 1993; Spitzer et al., 1994; Weisbrod et al., 1998). For this reason, we postulated the existence of a speciWc cognitive processing deWcit in these patients and, consequently, only thoughtdisordered schizophrenic patients were involved in our study.

Second, the proportion of related words in lexical decision tasks is another important factor: when this proportion is low (less than about 20% of the total verbal material), semantic priming abnormalities are observed in schizophrenic patients (Henik et al., 1992; Manschreck et al., 1988; Ober et al., 1995, Ober, Vinogradov, & Shenaut, 1997; Passerieux et al., 1995, 1997; Spitzer, Braun, Hermle, et al., 1993; Spitzer, Braun, Maier, et al., 1993; Vinogradov et al., 1992; Weisbrod et al., 1998), and especially in thought-disordered schizophrenic patients. This contrasts with the absence of certain semantic priming disorders when this proportion is higher (more than about 20% of the total verbal material) (Barch et al., 1996; Blum & Freides, 1995; Chapin et al., 1989, 1992). However, some exceptional data are reported in the literature because certain studies have found abnormal semantic priming in schizophrenics despite the use of lexical decision, identiWcation or pronunciation tasks containing a high proportion of related words (Aloia et al., 1998; Besche et al., 1997; Manschreck et al., 1988). However, these results relate to schizophrenic patients with very high levels of thought disorder. The essential role of the degree of structuring of the verbal material in the semantic priming deWcit is an important argument for the controlled nature of the deWcient processes in schizophrenics. In an earlier study, we showed that increasing the proportion of related words during a lexical decision task allows disorganized schizophrenics to improve the use of their semantic processing strategies (Besche-Richard & Passerieux, 2003). Here, we used two double lexical decision tasks in which the stimuli were presented simultaneously. This paradigm has been used twice with schizophrenic patients by Chapin et al. (1989, 1992) who observed an equivalent semantic priming eVect in schizophrenic and normal subjects. These authors interpreted their results as arguing in favor of the preservation of initial sensoryperceptual and automatic processing. Nevertheless, these studies included a large proportion of related words and there was no subgroup of schizophrenics with thought disorders. Here, and in order to specify the nature of the cognitive processes involved in a double lexical decision task, we decided to evaluate the eVects of varying the proportions of related words on controls’ and schizophrenics’ performances. Two proportions of related words, one high (25%) and one low (15%) were used.

2. Methods 2.1. Participants The participants consisted of 40 control subjects: 20 for the double LDT with 25% related words (Experiment 1) with 11 men and 9 women (age: 33 § 4; years of education: 12.5 § 2.86), and 20 for the double LDT with

C. Besche-Richard et al. / Brain and Language 95 (2005) 395–401

15% related words (Experiment 2) with 17 men and 3 women (age: 29.5 § 7.2; years of education: 11.8 § 2). Forty thought-disordered schizophrenic inpatients participated: 21 in the Experiment 1 with 13 men and 8 women (age: 31 § 7.3; years of education: 12 § 1.82), and 19 in the Experiment 2 with 15 men and 4 women (age: 34.7 § 8.6; years of education: 12 § 2.7). Schizophrenic patients were recruited from four clinical institutions: the Centre hospitalier de Versailles (Le Chesnay, France), the Pitié-Salpêtrière hospital (Paris, France), the MGEN clinic (Rueil-Malmaison, France), and the clinique de la Chesnaie (Chailles, France). There were no signiWcant diVerences between schizophrenic and control participants for the socio-demographic characteristics in Experiment 1. However, in Experiment 2 the patients diVered in age from the control subjects (p D .05). All participants were native French speakers. The diagnoses of schizophrenia were conducted in accordance with the Diagnostic and Statistical Manual of Mental Disorders-Revised (DSM-IIIR, American Psychiatric Association, 1987). The psychopathology of the schizophrenic participants was rated using the PANSS (Positive and Negative Symptoms Scale) (Kay, Fiszßein, & Opler, 1987) and the TLC (Thought Language and Communication scale, Andreasen, 1979) was used to evaluate the thought disorders. For the reasons mentioned earlier, we included only thought-disordered schizophrenic patients, i.e., those with high scores on the TLC scale (TLC score > 7). The mean TLC scores obtained by our patients were comparable with the scores observed in other studies involving disorganized schizophrenic patients (Andreasen & Grove, 1986; Besche et al., 1997; Besche-Richard & Passerieux, 2003; Blum & Freides, 1995; Passerieux et al., 1997). The clinical subgroups and a statistical analysis comparing the two groups of schizophrenics are presented in Table 1. The clinical evaluation of the psychiatric participants was performed by an independent psychiatrist who did not participate in this study. All the schizophrenic participants were receiving conventional antipsychotic drugs. None of these participants had a history of neurological disease, alcohol or drug abuse, or had electrocon-

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vulsive therapy (ECT) within the last 6 months. Informed consent was obtained from all participants. 2.2. Materials (see Appendix A) We used two double lexical decision tasks with semantic priming: one with 25% of related words (Experiment 1) and one with 15% related words (Experiment 2). In each task, there were Wve kinds of trials: related word, unrelated word, word–nonword, nonword–word, and nonword–nonword. We considered synonyms (e.g., hear–listen), antonyms (e.g., day–night), and categorically related items (e.g., apple–pear) to be semantically related words. A total of 40 diVerent pairs of related words were constructed. A counterbalanced design was used in which each target appeared in a diVerent type of item (related or unrelated) in each list of one task, so that each participant saw each word and nonword only once in the whole of the experiment. For each task, we constructed two sets of stimuli matched on word frequency (Trésor de la Langue Française, CNRS, 1971) and number of letters. These two lists each consisted of 20 of the 40 related pairs, 20 pairs of unrelated words, and 40 pairs containing a nonword. In Experiment 2, we added 27 pairs of Wller items (nonanalyzed unrelated words) to reduce the proportion of related words. These experimental lists were preceded by a practice list containing 61 items for Experiment 1 and 46 items for the Experiment 2. 2.3. Procedure All the participants were tested individually. In each task, the two strings of letters were presented simultaneously and the participants were instructed to make a double lexical decision. This means that they had to decide as quickly and accurately as possible whether the two strings of letters were real French words. They were told to respond “yes” if and only if the two letter strings of the pair were real French words, and “no” if at least one letter string was not a French word. In both cases, the stimuli were presented on a 14-in. Macintosh monitor connected to an Apple Macintosh

Table 1 Clinical characteristics of schizophrenic groups

TLC score PANSS score PANSS score, positive scale PANSS score, negative scale Length of evolutiona Chlorpromazine equivalent

Experiment 1

Experiment 2

Comparison between the groupsb

20 § 7.2 83 § 17.2 18 § 4.6 22.4 § 6.7 9§5 1071 § 992

17.7 § 7.1 80.4 § 18.2 17.7 § 5.4 23.4 § 6.2 10.5 § 6.8 810 § 485

t (1, 38) D 1.02, ns t (1, 38) D 0.46, ns t (1, 38) D 0.46, ns t (1, 38) D ¡0.5, ns t (1, 38) D 0.44, ns t (1, 38) D 0.55, ns

Means, standard deviations, and statistical tests. ns, nonsigniWcant. a Length of evolution is indicated in years. b Student test for independent groups.

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Powerbook portable, model 165, which controlled stimulus presentation and data collection (reaction times in milliseconds and error rates as a percentage value). All the prime and target words were written in lower case letters in 36-point Geneva font (9 mm in height) and appeared centered on the screen. The participants gave their responses by pressing one of two keys on the computer keyboard (“Q” for “no” responses and “M” for “yes” responses for a right-handed participant). The participants used their dominant hand to indicate their “yes” responses. In the two lexical decision tasks, the target items remained on the screen until the participants responded. The intertrial interval was 1500 ms.

3. Results For each of the experiments, we shall present an analysis comparing the controls and the schizophrenic participants. For each task, repeated-measures analyses of variance (ANOVA) on reaction times (RTs) and then on error rates (ER) were conducted with Condition (related–unrelated) as within group factor and Group (control vs. schizophrenic participants) as between group factor. To control for the eVect of the reaction times on the amplitude of semantic priming, we calculated a percentage gain in the same way as Spitzer, Braun, Hermle, et al. (1993): 1 ¡ (RTsRC/RTsUC) £ 100, where RTsRC is the reaction times in the related condition and RTsUC is the reaction times in the unrelated condition. Next, we analyze the correlations between the clinical variables (TLC score, PANSS total score, PANSS positive subscale score, PANSS negative subscale score, length of evolution, and chlorpromazine dosage) and the main experimental variables (global reaction times, global error rates, and semantic priming eVect). The means and standard deviations of the results are presented in Table 2. For each task, the eVects of the two lists on RTs, ERs, and priming eVects were examined in the control participants. Neither the main eVects for lists nor the Groups £ Lists interaction were signiWcant for reaction times or for error rates except in the second double LDT (list eVect for error rates in Experiment 2, p D .01). To

analyze the error rates in the double LDT in Experiment 2, we decided to introduce the task lists as a covariable. In neither of the experiments was there any signiWcant correlation between age, years of education and global RTs, ER and semantic priming. There was no semantic priming diVerence in either group between men and women. 3.1. Experiment 1: Double lexical decision task with 25% of related words As far as the RTs were concerned, a repeated-measures ANOVA revealed highly signiWcant eVects of group [F (1, 39) D 27.1, p D .0001] and condition [F (1, 39) D 56.64, p D .0001], but the interaction between these factors was not signiWcant [F (1, 39) D 1.76, p D .19]. We observed (see Table 2) that the schizophrenic group exhibited longer RTs than the control group but no signiWcantly diVerent semantic priming eVect. Moreover, there was no signiWcant diVerence between the percentage gain in the schizophrenic and control participants [F (1, 39) < 1]. A second identical repeated-measures ANOVA was performed with ER as the dependent variable. There was no signiWcant eVect of group [F (1, 39) D 2.4, p D .13] or condition [F (1, 39) D 1.86, p D .18], and no signiWcant interaction [F (1, 39) < 1]. The error rates were comparable in the two groups. The analyses of the clinical and experimental variables revealed a signiWcant correlation between the total error rates and the chlorpromazine dosage (r D .54, p D .01): the more neuroleptics taken by the schizophrenics, the more errors they made in this lexical decision task. 3.2. Experiment 2: Double lexical decision task with 15% of related words The Wrst repeated-measures ANOVA comparing the control and schizophrenic participants revealed signiWcant eVects of group [F(1, 37) D 6.6, p D .01] and condition [F(1, 37) D 78.8, p D .0001], but no signiWcant interaction [F(1, 37) D 1.39, p D .25]. These results indicate that the schizophrenic participants had longer reaction times than the control participants, although there was no signiWcant diVerence in the semantic priming eVects between the two

Table 2 Means and standard deviations of reaction times (RTs) and error rates (ER) in the related and unrelated conditions and the percentage gain in the control and schizophrenic groups for each experiment Experiment 1

Experiment 2

Related condition

Unrelated condition

Related condition

Unrelated condition

RTs (ms)

RTs (ms)

RTs (ms)

ER (%)

RTs (ms)

ER (%)

ER (%)

ER (%)

Controls Percentage of gain:

770 § 84 9.55 § 4.1

1.5 § 2.3

853 § 101

2.25 § 3.8

915 § 162 9.44 § 5.2

3.06 § 4.8

1009 § 153

2.25 § 4.4

Schizophrenics Percentage of gain:

1051 § 238 9.92 § 8.7

2.9 § 4.7

1170 § 256

4.52 § 6.7

1067 § 244 10.22 § 7.42

0.26 § 1.1

1190 § 249

1.31 § 2.8

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groups. As in Experiment 1, there was no signiWcant diVerence in the percentage gains between control and schizophrenic participants (F (1, 37) < 1). A repeated-measures ANCOVA, with the task list as covariable, was performed with ER as the dependent variable and yielded no signiWcant eVects. The analysis comparing the clinical and experimental variables showed no signiWcant correlation.

4. Discussion In the two double lexical tasks used in this research, we found an identical semantic priming eVect in normal controls and schizophrenics patients. This Wnding conWrms previous published results found in nonthoughtdisordered schizophrenic patients (Chapin et al., 1989, 1992). Generally speaking, although the decision times observed in the two tasks were quite long, they nevertheless lay in the range that is generally observed in these experimental situations (Anderson & Holcomb, 1995; Chapin et al., 1989; Perea & Rosa, 2002). This increase in response times can be simply explained: the subject’s task is to make a lexical decision on the two items of each pair and not simply on the second target item as in more conventional situations. This is an obvious reason for the increase in response times compared to more conventional situations in which subjects have to make a lexical decision on the target only. The amplitude of the semantic priming eVect is not inXuenced by the proportion of related words: in normal controls, the semantic priming eVect had a value of 83 ms in the Wrst experiment (high proportion of related words), and 86 ms in the second (low proportion of related words). As in the control group, the degree of structuring of the verbal material (proportion of related words) had no inXuence on the amplitude of the semantic priming eVect: this eVect had a value of 119 ms in the Wrst experiment and 117 ms in the second. Very few studies have investigated the eVect of the proportion of related words on semantic priming during double lexical decision tasks. Perea and Rosa (2002), using two double lexical decision tasks, obtained a semantic priming eVect that reached signiWcance in the tasks with low and high proportions of related words (18 vs. 82%); the semantic priming eVect was signiWcantly higher in the task with a high proportion of related words than in the task with a low proportion of related words. It should be noted that the authors did not obtain an eVect of the proportion of related words when they used sequential lexical decision tasks with short SOAs (116 and 166 ms, Experiments 2–5). In our study, the variation in the proportions of related words (15 vs. 25%) was insuYcient to reveal a proportion eVect. The results obtained by Perea and Rosa (2002) thus suggest that controlled processes are involved in double lexical deci-

399

sion tasks and that these processes are intact in schizophrenia patients under these experimental conditions. In eVect, in these two experiments, schizophrenic patients with thought disorders exhibited a pattern of responses similar to that of normals except for the presence of an increase in global reaction times. These patients exhibited a signiWcant semantic priming eVect reXecting, in these lexical decision tasks, their ability to process the semantic context. These results therefore point to the eVective mobilization of the processes involved in the processing of semantic context in disorganized schizophrenics. They are reminiscent of those obtained by Henik et al. (2002) who showed that in a Stroop test, schizophrenia patients were able to reduce the interference phenomena as a function of the proportion of neutral items presented in the task. This result led the authors to conclude: “Although many studies have suggested that schizophrenia patients have impaired context processing, the present results suggest that this may be a function of the context representation involved” (p. 147). In the tasks that we used, we asked the subjects to make their lexical decisions on both components of each pair. This instruction suggests that the subjects should take account of the semantic relations between words. These experimental conditions would therefore seem to permit schizophrenic subjects to make use of the context. Within this perspective, we have already shown that the use of a double lexical decision instruction (joint consideration of the prime and the target) in a sequential task (SOA, 500 ms) (thus with more explicit instructions), thus mobilizing the use of postlexical processes, can normalize the performances of disorganized schizophrenic patients (Besche-Richard & Passerieux, 2003). These results contrast with the majority of studies which have revealed anomalies in this type of cognitive processing in these patients. This would therefore mean that disorganized schizophrenic patients are sensitive to the experimental conditions: the diYculties these patients experience in processing the semantic context are undoubtedly related to the relevance and salience of the elements that constitute this context (mode of stimulus presentation, proportion of related words, and explicit or implicit instructions). This result is important when we consider possible remedial techniques for these patients. Nevertheless, these initial results still need to be conWrmed in a larger group of disorganized schizophrenia patients using methods which more speciWcally evaluate the postlexical checking strategies.

Acknowledgments We are grateful to Jean-Paul Laurent, Juan Segui, Sophie Kecskemeti, and Gérald Mesure for their assistance during this research.

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Appendix A Related condition

Unrelated condition

Experiment 1 1. Old (Ancien) 2. Page (Page) 3. Mouse (Souris) 4. Worst (Pire) 5. North (Nord) 6. Fear (Craindre) 7. Start (Début) 8. Violin (Violon) 9. Day (Jour) 10. Naughty (Méchant) 11. Roof (Toit) 12. Acute (Aigu) 13. Peach (Pêche) 14. Horse (Cheval) 15. Indoors (Dedans) 16. Apple (Pomme) 17. Cry (Pleurer) 18. Father (Père) 19. Nose (Nez) 20 For (Pour)

New (Nouveau) Book (Livre) Rat (Rat) Best (Mieux) South (Sud) Dread (Redouter) End (Fin) Piano (Piano) Night (Nuit) Bad (Mauvais) House (Maison) Grave (Grave)a Apricot (Abricot) Stable(Ecurie) Outdoors (Dehors) Pear (Poire) Laugh (Rire) Mother (Mère) Mouth (Bouche) Against (Contre)

Far (Loin) Count (Compter) Water (Eau) Egg (Œuf) Well (Bien) Here (Ici) Salt (Sel) Before (Avant) Tea (Thé) Full (Plein) Table (Table) Monday (Lundi) Hear (Entendre) Give (Donner) Sun (Soleil) High (Haut) Sofa (Divan) Motorbike (Moto) In front (Devant) Oar (Rame)

Low (Bas) Listen (Ecouter) Elsewhere (Ailleurs) Bad (Mal) Chicken (Poule) Wine (Vin) Car (Voiture) Empty (Vide) Pepper (Poivre) Near (Près) Week (Semaine) Couch (Canapé) Calculate (Calculer) Behind (Derrière) Chair (Chaise) Boat (Barque) Take (Prendre) CoVee (Café) Afterwards (Après) Moon (Lune)

Experiment 2 1. Monk (Moine) 2. Cloud (Nuage) 3. Currency (Monnaie) 4. Field (Champ) 5. Milk (Lait) 6. Smoke (Fumée) 7. Dirty (Sale) 8. Boy (Garçon) 9. Chest (Commode) 10. Brother (Frère) 11. Little (Peu) 12. Leg (Jambe) 13. Trousers (Pantalon) 14. Painter (Peintre) 15. Morning (Matin) 16. Oak tree (Chêne) 17. Read (Lire) 18. Uncle (Oncle) 19. Joyous (Gai) 20. First (Premier)

Priest (Prêtre) Rain (Pluie) Coin (Pièce) Meadow (Prairie) Cow (Vache) Fire (Feu) Clean (Propre) Girl (Fille) Sideboard (BuVet) Sister (Sœur) Lots (Beaucoup) Arm (Bras) Skirt (Jupe) Builder (Maçon) Evening (Soir) Beech tree (Hêtre) Write (Ecrire) Aunt (Tante) Sad (Triste) Last (Dernier)

Joy (Joie) Lie (Mensonge) Win (Gagner) Happy (Heureux) Left (Gauche) Blackbird (Merle) With (Avec) Tire (Pneu) Racket (Raquette ) Yesterday (Hier) Airplane (Avion) Iron (Fer) Early (Tôt) Parent (Parent) Worker (Ouvrier) Coat (Manteau) Doe (Biche) Spade (Bêche) Carrot (Carotte) Pencil (Crayon)

Wheel (Roue) Celery (Céléri) Happy (Joyeux) Lose (Perdre) Factory (Usine) Ship (Bateau) Late (Tard) Happiness (Bonheur) Blouse (Blouson) Pen (Stylo) Right (Droite) Deer (Cerf) Zinc (Zinc) Rake (Râteau) Pigeon (Pigeon) Tennis (Tennis) Without (Sans) Child (Enfant) Truth (Vérité) Tomorrow (Demain)

a

Acute and grave are both types of accents used in written French.

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