Monthly Archives: March 2014

Literacy and Auditory-verbal practice

Stacey Lim bio

Literacy is the ability to use printed and written information to function in society to achieve one’s goals, and to develop one’s knowledge and potential.
-National Assessment of Adult Literacy

When I was in high school, I read a statistic that the national reading average for adults who were deaf was a fourth grade reading level. To me, that was a shocking and sobering statistic.  This statistic has remained constant through the years.  When I read that statistic, I could not imagine graduating from high school with a fourth grade reading level.  Throughout my undergraduate and graduate programs, I focused my research on cochlear implants and their function. However, I have always been interested in literacy and how children learn to read.  Over the past few years, I have also begun to explore literacy and the reading skills possessed by children who are deaf and hard of hearing.

The ability to succeed in a variety of academic courses,
such as science, mathematics, history, English, among many other subjects,
is dependent on the reader’s ability to extract information from texts.

Reading is the foundation of these topic areas, and children who struggle to read generally have difficulties understanding text-based information in their other courses.  For some children, this struggle becomes so insurmountable that they drop out of school. In our information-driven society, we are constantly accessing print in many forms, including paper-based and online formats.  Thus, reading impacts many different arenas of a person’s life, and extends beyond the classroom, affecting other opportunities such as workplace advancement.  Given our increasing dependence on printed matter and our increased focus on higher education, giving our auditory-verbal children access to a language-rich environment is critical for their future successes.


Reading comprehension is at the very core of literacy.  This complex task consists of a variety of component skills, including word recognition and vocabulary knowledge. Word recognition consists of several different components, including orthographic knowledge. Orthographic knowledge is our understanding of letters and how they are combined in a language. For example, we know that in the English language, vge can never be at the beginning of a word.  However, recognizing words extends beyond simply understanding the orthographic construction of a word, and also requires knowledge of the alphabetic principle and phonological awareness skills.

The alphabetic principle refers to the understanding that different letters of the alphabet represent spoken words, while phonological awareness is understanding of the relationship between letters and sounds (sound-to-letter mapping).  These skills have been shown to impact reading comprehension skill.

Research has suggested that reading comprehension appears to be influenced by phonological skill.  Even before a child begins to learn to read, he or she becomes a pre-reader, and in this stage of reading development, becomes aware of print and sound. Further, the child begins to make associations between print and sound.  In auditory-verbal practice, the child with hearing loss has access to spoken language, thus is able to build the sound-to-letter mapping relationships used in decoding printed words.  This developing skill, in auditory-verbal practice, is highly dependent upon appropriate auditory access. The audiologist plays a role by (1) assessing the child’s hearing ability on a regular basis, (2) providing appropriate hearing technology, including hearing aids, cochlear implants, and FM systems, and (3) working with the parents to ensure that the child’s auditory environment is optimal for language learning.

Written language and spoken language share a common linguistic base.  Word knowledge is one of the largest contributors to later reading comprehension. For an auditory-verbal child, the ability to access spoken language allows them to access a wide range of vocabulary, which is necessary for understanding text-based information.  Hart and Risley (1995) investigated the amount of language and vocabulary exposure occurring in children’s homes, and what they found is that 86% to 98% of the children’s vocabulary was dependent on their parents’ vocabularies. In other words, the more words that children heard their parents say, the more exposure children had to a varied, large set of words, which then became part of the child’s permanent vocabulary set.  Children with hearing loss may have more difficulty with this task because of the acoustic filter caused by hearing loss, but audiologists can play a key role in alleviating this challenge.

One key point to consider is the idea of incidental listening.  In general, we tend to learn words incidentally—these words are generally not purposefully taught (just think of all the bad words or slang we learned—they were not learned in a formal instructional setting. Rather, we overheard them being used conversationally).

Incidental learning is more difficult for children with hearing loss,
because the range of hearing is lessened. Thus, the audiologist’s role
would be to ensure that the child has access to sound in a
variety of settings and across various distances. 

To bring the primary speaker’s voice closer to the child’s ears with minimal loss of sound quality, the audiologist will need to fulfill the second Principle of Auditory-Verbal therapy by using appropriate hearing technology.  In addition to programming the child’s hearing aids and/or cochlear implant(s) to provide maximal auditory access, the audiologist should encourage the use of an FM system. This FM system can be worn at home, with the parents using the transmitter and the child wearing the receiver. In this way, the child will be able to hear his or her parents’ voices, as if they were next to him or her.  Thus, the child will have access to a fuller range of vocabulary and the nuances of spoken language.

The fourth Principle of Auditory-Verbal therapy states that parents are the primary facilitators of their child’s language learning, and the fifth Principle states that environments conducive to listening for language learning is critical.  To create a literacy-rich environment that will lead to greater phonological awareness, better letter knowledge, and better vocabulary, the audiologist can work with the family to help them create an acoustically accessible environment to promote literacy and language learning. In addition to facilitating the use of appropriate hearing technology, the audiologist can work with the family to make some adaptations to the existing home environment to ensure that background noise is at a minimum. For example, parents may want to turn off the television and any other appliances that may make loud noises that interfere with their speech productions.

Not only is it important to provide access to conversations that are rich in everyday language, but as Emilie Buchwald wisely said, “Children are made readers on the laps of their parents.” Indeed, reading aloud to children is one of the best ways to build language and literacy skills. Again, providing auditory access to the parents’ voices allows children to create a social activity where conversational techniques are used.  Parents can use the FM system or read next to their children, so that their voices are heard clearly.

By promoting appropriate acoustic access to spoken language, the audiologist gives the parents the skills to help their children develop age-appropriate reading skills that carry them through life. William James wrote: “So it is with children who learn to read fluently and well: They begin to take flight into whole new worlds as effortlessly as young birds take to the sky.”


Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experience of young American children. Baltimore, MD: Paul H. Brookes Publishing.


We appreciate your interest in this blog post. The text contained in it is copyrighted by SoundIntuition as of the date of publishing. Contact us by leaving a comment on this post if you would like to use this text elsewhere. When used, we would ask that you cite this page, using the full URL (, as being the originator of the content. 

Partnering with parents/caregivers is pivotal to success

Rebecca SiomraTo learn, we go to school.
To feel better, we go to the doctor.
To maintain our car, we go to the mechanic.
To get our children to communicate, we go to the speech-language pathologist.

While there is some truth to all of these statements, there is also a lot more involved in reaching the desired outcomes.

More complete statements might be:

To learn, we read books, go online, talk to mentors, and do assigned homework from a teacher.
To feel better, we eat well, exercise, get plenty of rest and follow a doctor’s recommendations.
To maintain our car, we fill it with gas, drive with caution and follow the prescribed maintenance schedule.
To get our children to communicate, we can go to a speech-language pathologist who will do what? Work her magic? Fix the problem? What goes on behind that door, anyway?

I don’t know about my colleagues, but when I graduated
from school as a speech-language pathologist,
I was not given a magic wand, and therefore, I would say that
my role is to help our children learn to communicate,
we can seek the guidance of a speech-language pathologist. 

One of the privileges of working as a speech-language pathologist with young children is having the opportunity to coach parents and caregivers. Children grow and change, with or without us — it’s what they do. Parents and caregivers help guide this development every day in whatever they do together and have the amazing opportunity to help the children in their lives reach their potential, even through unexpected challenges.  I’m so fortunate to be able to tag along for the ride.

Let’s face it, parenting can be unpredictable journey, it certainly doesn’t come with a roadmap and when a child needs added support in learning to communicate, it can become very overwhelming.  Whether a child needs help learning to listen, talk, understand or communicate and interact with others more effectively, the first stop is often to the doctor’s office for advice and referrals to a ‘specialist’.

In the past, when a family would arrive for a therapy appointment with the speech-language pathologist, the parents would sit in one room and the child would disappear into another with the ‘specialist’.  In some offices, the parents might watch the session through a two-way mirror.  The session would end, and the therapist might hand the parents a page with homework activities, comment on how the visit went and chat briefly with them about how to prepare for the next session, before sending them on their way.  Everyone would part with a satisfied feeling that steps were being taken to help the child.

Times certainly have changed and many professionals have returned to the teachings of the well-known proverb, ‘Give a man a fish and you’ll feed him for a day, but teach a man to fish and you’ll feed him for a lifetime.’  It is now common practice for parents to be in the therapy room with their child and be an active participant in the session so that they may be more confident in following through with homework.

Damian's mom is an active participant and a valued part of her son's communication strategy

Damian’s mom is an active participant and a valued part of her son’s communication strategy

Today there is also another player in sessions; parents have the Internet and aren’t afraid to use it.  Parents have the ability to ‘Google’ anything they wish about their child’s communication needs. This raises a lot of great questions, as well as some fears, and they need answers.

When parents and caregivers are able to participate in a therapy session, it allows them to build a relationship with the therapist and to become comfortable enough to ask the hard questions they aren’t sure they want the answers to, like: “Will my baby ever look up when I call his name?”, “Does she have autism?”, “Is it my fault that she can’t speak?”.

A parent’s questions can teach a therapist a lot about what kind of support a family needs, and how ready they are to take on a more active role in sessions. Once a parent/caregiver is comfortable with participating, they will are able to learn how to guide their child in becoming a better communicator.

Therefore, I do not operate as the one who will ‘fix the problem’ — we’re working together, to the advantage of the child. When a parent or caregiver is part of a session, I’m able to join them in play with their child. (Admittedly, I provide toys/games/activities that will tap into an area of challenge for the child, but this also helps the family to know what they could play with at home!) I have the opportunity to observe how they interact together, and, through modelling, I can demonstrate new strategies that encourage communication development based on the child’s individual needs and provides on-the-spot coaching to give the parent or caregiver the chance to try it out, ask questions, then try it out again. We work together, as a team, to help their child to take steps forward. I’m not the one going home with the child.

When a parent knows that they know how to play/talk in a way that helps their child to do something new, they are much more likely to keep doing it at home. When parents are able to effectively carry new tools into their everyday lives, their child has endless opportunities to practice his/her new skill.

With practice comes confidence, and the opportunity to move forward.
I’m not the one pedalling the bike, the parent is…
I’m just the training wheels.

Parents will often comment, “I can’t believe I’ve been doing this wrong the whole time! I know that I spoke the same way to my other kids and they’re okay.”, and I’m quick to jump in and correct. Parents’ instincts in how they talk to their children are usually just fine! When a child has a communication delay/disorder, the rules change, they learn differently.

One of my roles, as a speech-language pathologist, is help parents learn to work with those differences and to teach/guide their child in a new way. The children that I work with are very young and are not able to change the way they learn to suit the adults in their world. We need to adjust to their level and work with them. This is true for a wide variety of challenges, including a difficult-to-engage toddler, a baby who has just had their cochlear implants activated, or a preschooler who is struggling with the motor-planning of speech sounds.  Regardless of the labels behind the disorders, the names of techniques or the therapist that you work with, parent/caregiver participation and follow-through are essential in helping their children reach their potential.

When parents are willing to actively take part in a therapy session,
accept coaching, ask questions and practice at home,
that’s when the magic happens. I don’t need that wand after all!


We appreciate your interest in this blog post. The text contained in it is copyrighted by SoundIntuition as of the date of publishing. Contact us by leaving a comment on this post if you would like to use this text elsewhere. When used, we would ask that you cite this page, using the full URL (, as being the originator of the content.

My clinic piano as a teaching moment… for me.

Dr. Marshall Chasin

I have long known about the research of Dr. Brian Moore, specifically about his work with dead regions in the cochlea.  I have even purchased and used the TENS test to determine whether or not a region was healthy  enough to receive amplified sound.  “Cochlear dead regions” is a phrase that refers to a very significant amount of damage to the inner hair cells in the cochlea such that amplification with hearing aids may not be a good thing.  This is a case where less may be more.

Academically I know about “cochlear dead regions” and have even spoken about them; the literature has been discussing this issue for more than a decade.  But only recently have I begun to really use that knowledge.  In the past it was almost as if I was being macho and felt that the more gain I could give my clients at 4000 Hz (the top note on the piano keyboard), the better job I was doing.  And, of course, I “knew” my clients would hear better- never mind that that was not always the case. After all, as a macho audiologist, I knew better.

Back then, I felt, “cochlear dead regions” was a subject better left to the ivory towers of universities, and if my clients couldn’t use the amplification I gave them, that was their problem!

Of course, I am being tongue in cheek.  In the vast majority of hearing aid fittings, because of the limitations of modern hearing aid technology and the severity of a person’s high-frequency hearing loss, insertion gain measures would generally fall short of the “target” gain at 4000 Hz.  It is a rare situation where I can actually achieve the desired gain at 4000 Hz in any event, so  why worry about specifying less gain?

Clinically I would do everything to enhance the amount of amplification in the higher frequency region- I would program the hearing aid to generate that gain.  I would use acoustic plumbing to ensure that the earmold coupling was as optimal- I even referred to myself as a “dB squeezer”- someone who got those last few dBs out of a hearing aid fitting, like squeezing the last bit of toothpaste from the tube.

But back to “cochlear dead regions”.  Once a cochlear dead region is suspected, the clinical approach is to stay away from that frequency region.  One would typically reduce the amount of amplification in that frequency region(s) or perhaps use frequency transposition to shift the effective amplification to a lower (and hopefully) healthier cochlear region.  But even though I knew that intellectually, it wasn’t until recently, when I started to use my clinic piano, that it was driven home.  The piano is now part of my clinical armament- almost as useful as my audiometer.

Here’s how it works.  I have my hard of hearing clients (with or without their hearing aids) sit down and start playing the notes sequentially from about 1000 Hz and up … white key, black key, white key. One thousand Hz is about two octaves above the middle of the piano keyboard and about half way between the middle (near 250 Hz) and the top note (4000 Hz).  I ask clients to tell me when they can no longer distinguish between two adjacent notes.  For example, they may find that starting around G, that G and G# sound about the same pitch.  This corresponds to 1500 Hz (or perhaps 3000 Hz if it’s in the top octave of the piano).  This is an area that I want to stay away from.

The following table gives some “approximate” frequencies and their corresponding musical notes starting at middle C (the middle of the piano keyboard):


Of course, middle C is not 250 Hz; it is 262 Hz, and the top note on the piano keyboard C is not 4000 Hz; it is 4186 Hz, but the numbers in the table are close enough.  This takes about 15-20 seconds and gives clients a sense of being involved in their hearing rehabilitation.  Interestingly enough, this corresponds well with the results of Dr. Moore’s TENS test- actually not so surprising since this is really just another way of assessing the same phenomenon.  A comparison of Dr. Moore’s TENS test and this adjacent piano note test would make an interesting Capstone project for some AuD student.

I saw two hard of hearing musicians earlier in the week whom I have been seeing for at least 1000 years.  They had complained about “fuzziness” despite my best macho audiology tactics.  After this brief piano test, I reduced the gain above 2000 Hz in one ear (and bilaterally for the other musician) and the fuzziness went away.  I had to explain that I knew about this for the past decade but was too clinically pig-headed to do anything about it!

Although I have not done a statistically valid survey of audiology clinics, I suspect that most clinics do not have a piano in their office.  However, this is not an issue of pitch perception or even one of “just noticeable difference”.  It is a simple issue of “same” or “different”.

A $25 Cassio 1970s kid’s piano keyboard would do the trick, and you can still  find them for sale at low-end electronics stores or at many garage sales.  Pull out the portable keyboard, ignore its tuning, and just go to work.  Are two adjacent notes the “same” or “different” is all we need to know.  If two adjacent notes are the same, then minimize the amount of hearing aid amplification in that region.


Republished with permission:

Common Myths about AVT (part 1 of series)

Karen MacIver-Lux


I once attended a conference of audiologists and while waiting for the shuttle bus to take me back to the hotel, an audiologist approached me to ask how I was enjoying the conference. After we had exchanged introductions and information about our practices, she asked a number of questions that we have decided to share in a series of blogs in the hope that we can dispel some of the misunderstandings about Auditory-Verbal Therapy. 

Question One:
“Why do you auditory-verbal therapists insist on covering your lips while speaking?  It’s so unnatural looking, don’t you think?”

Ah.  The hand cue.  Yes, it is unnatural looking.

Advances in hearing science and hearing technology over the past few decades have caused auditory-verbal therapists around the world to reconsider their use of the hand cue. Historically the hand cue has been used to prevent speechreading but in actual fact it makes it more difficult for children with hearing loss to hear the speech clearly.  In my opinion, it also sends a subliminal message to the child that we don’t trust that they are listening unless we cover our lips. If we don’t trust their listening, how can they learn to trust their own hearing and listening skills?  Auditory-verbal therapists are now using alternative techniques and strategies to encourage children to listen.  In the 101 FAQs about AVT (page 113), there is an excellent response regarding the use of the hand cue in Auditory-Verbal practice and alternative techniques that can be used to foster confidence in listening.

Question Two:
“I thought that if you cover your lips when you speak, then it’s called Auditory-Verbal Therapy!  I’m confused!”

There is a lot more to Auditory-Verbal Therapy than just encouraging children to listen.  In fact, in the auditory-verbal approach, the parent(s)/caregiver(s) are the primary clients, not the children.  In every session, the auditory-verbal therapist invites the parent(s)/ caregiver(s) to actively observe and participate during the process of:

  1. selecting and using techniques and strategies that are used to gain diagnostic information about the child’s current skills in areas of audition, speech, language, cognition and communication during the session and at home;
  2. selecting session targets and long term goals that are appropriate according to the child’s chronological age, hearing age, developmental age, culture and interests.  Parents learn to navigate and document their child’s acquisition of developmental milestones with their hearing technology;
  3. choosing which techniques and strategies work best in helping make spoken language and the sounds of the environment easier for the child to hear and process;
  4. reporting on the child’s current skills, strengths and challenges and advocating for additional supportive services when necessary; managing the child’s hearing health, use of and benefit from hearing technology, and accessibility to learning opportunities (within and outside an educational setting) that’s easy to hear;
  5. transferring the above learned skills to their children so they can take responsibility for their own hearing, listening and spoken communication skills, and their self advocacy during all life situations.

Question Three:
“Aren’t those who follow the auditory-verbal approach against American Sign Language (ASL), Cued Speech, and other intervention approaches that include the use of visual cues?”

Every child with hearing loss is unique so it is important that parents of children who have hearing loss have an abundance of options when it comes to choosing an intervention approach that best meets the needs of their child and the family.  It is absolutely crucial, that no matter the decision, the family’s choice is respected and supported by all professionals with whom the family comes in contact with.

Karen in therapy session

There are some auditory-verbal professionals who are proficient in sign language but the majority are not.  There are some children and parents who come to auditory-verbal therapy with some sign language skills, but most do not.

When families choose the auditory-verbal approach, they make a commitment to help their children learn spoken language through listening with appropriately fitted hearing technology by following the Ten Guiding Principles of Auditory-Verbal Practice, and engaging the guidance of an auditory-verbal professional.  Although the auditory-verbal professional would not provide sign language instruction, it does not mean that an auditory-verbal therapist would discourage a child from using sign language if that is indeed what the child currently uses to communicate.

Here’s an example of an Auditory-Verbal Therapy session I conducted with a child who was using sign language when I began seeing her.

Sally is a child with a bilateral profound hearing loss who at 18 months of age had developed age appropriate skills in sign language.  Sally’s parents made the decision to proceed with cochlear implantation, and just prior to activation of her cochlear implant, enrolled her into the auditory-verbal therapy program. At the time of Sally’s first auditory-verbal session, she had been listening with her cochlear implant for one week and her chronological age was 20 months.   After providing Sally’s mom with the session targets (a few of which are listed below), I proceeded to begin the Learning to Listen (LTL) Sounds lesson.

Audition: Show detection responses to all LTL sounds by stopping activity, turning head in the direction of the sound, and pointing to their ear (“I hear that!”)

Speech: Make approximations of the LTL sounds using vowel sounds and match suprasegmental features of speech.

Language: Follow simple directions such as “Wave bye bye!”

Cognition: Demonstrate evidence of associating the LTL sound with the object (sound-object association) and associate the LTL sound with the known sign.

Communication: Demonstrate appropriate eye contact with the speaker; make attempts to put verbal approximations or LTL sounds with natural or signed gestures.

While Sally was engaged in a quick cuddle with mom, I quickly placed a dog wind-up toy in a little box and shook it and waited.  Sally became quiet and looked at her mom.

After waiting a few seconds more, I shook the box again and waited.  Sally looked over in my direction where she saw the box.  I pointed to my ear and said, “Did you hear that Sally?”

Sally leaned over to take a closer look at the box and looked back at her mother and made the sign for box.  Mom nodded her head and said, “Yes! Karen has a box!”

I laughed and Sally looked over at me.  “Did you hear me laugh? Let’s listen to the box again.” And I shook the box.

Mom said, “I hear something in the box.  Karen, what is it?”

I replied, “It’s a dog! Do you know what the dog says?”

Mom replied by saying “Woof, woof” and then she waited.   Sally looked over at mom, smiled and mom exclaimed, “You heard the doggie!”

After waiting a few more seconds, I said, “woof, woof!”  Sally turned in my direction, and I smiled “I think you heard the dog again! Let’s open the box and see what’s inside!”

When we opened the box, Sally smiled and made the sign for the dog.  Mom replied, “Yes, it’s a dog!  You’re right!”

I then proceeded to guide the mom to make the sound for the dog, and look expectantly at Sally.

Sally repeated the sign for the dog and looked at me.  I smiled and said, “You have the dog!  Lucky girl!  Let’s play with the dog.”

Over the next few minutes we proceeded to take turns making the dog walk, bark, jump, run around and around.  After Mom and I barked a few times, Sally said “mm mm!”  Mom said, “Yeah, I heard your doggie go woof, woof!”

Once it appeared that Sally was becoming disinterested in the dog, I said, “Let’s put the doggie away in the bucket and bring out a new toy.  Wave bye-bye!”  We all took turns waving to the doggie and put the dog in the bucket.

The lesson continued with the rest of the LTL toys.  Throughout the session, we monitored Sally’s auditory responses to our voices, to the LTL sounds, and the spoken language we provided.  After following the same routine with five more toys, Sally began to show understand of the direction by waving every time someone said, “Wave bye-bye!” Mom and I discussed and recorded Sally’s auditory responses, signs, and spoken language attempts.  We then discussed ways that Mom could incorporate LTL sounds into the family’s daily routines.

Signs made by the children during auditory-verbal sessions are acknowledged and responded to by using spoken language, facial expressions and gestures.  At no point do I discourage a child from using sign language.  I demonstrate to the parent(s) and caregiver(s) the use of techniques and strategies that will support the development of spoken language primarily through hearing and listening with the children’s hearing technology and I quickly hand over the activities to the parents so they can practice while I coach on the sidelines.  After all, it is the parents who are their children’s primary spoken language models.

Auditory-verbal therapists are privileged to be members of a team of professionals supporting families who are helping their children with hearing loss reach their highest listening and spoken communication potential.  It is a truly privilege to be a part of this wonderful profession, and I endeavour serve all families and professionals with respect, integrity and kindness as their auditory-verbal therapist.


Resources: 101 FAQs About Auditory-Verbal Practice (Estabrooks, 2012): renowned experts in the field provide up-to-date information — current theory, practice, and evidence based outcomes. 101 FAQs offers knowledge, guidance and encouragement for speech-language pathologists, audiologists, teachers, doctors, schools, and parents.

We appreciate your interest in this blog post. The text contained in it is copyrighted by SoundIntuition as of the date of publishing. Contact us by leaving a comment on this post if you would like to use this text elsewhere. When used, we would ask that you cite this page, using the full URL (, as being the originator of the content.

Do I need an AVT therapy room in my house?

Melanie Ribich short bio

Two of the questions I used to ask myself was, do I need to set up a therapy room in my house? How often do I need to sit down and do therapy with my child?

Elizabeth Rosenzweig of Cochlear Implant Online wrote, “in Auditory-Verbal Therapy, parents come to center stage to play a key role in the show.”

As a mom, I realize that active parent involvement in the therapy process is key to my son’s success and came to understand that was crucial for me to learn how to be my son’s pseudo therapist. Even with the best therapy, one hour once a week was not going to be enough for him to develop age-appropriate listening and spoken communication skills.

I have to admit, that although I loved the idea of being in charge
of my son’s progress, I was pretty worried during the early stages
of my son’s auditory-verbal intervention.

I learned that children with hearing loss need to hear a word or phrase three to four times more often than children with typical hearing before they master it receptively and expressively. I learned that 95% of a child’s receptive and expressive prowess is gained through overhearing adults engaged in conversational exchanges at extended distances.

Prior to cochlear implants, my son couldn’t hear a thing with his hearing aids. How was my son going to overhear my husband and I talk if he couldn’t hear? How was I going to do all that I needed to do, without replicating exactly what our therapist did with Noah every week when she came to our home?

AVT sessions do not consist of the therapist simply disseminating information, but rather, it’s an hour of therapist demonstration and parent practice with the purpose of enabling parents to feel confident using techniques and strategies that encourage the development of spoken language through listening. Auditory-verbal therapists understand that therapy is a process that does not end when their hour does. They guide and coach parents in creating and maximizing listening and spoken learning opportunities within their daily routines.

How was I ever going to find the time, resources,
and creativity to replicate what my therapist was able to do
every Friday morning in our living room? I felt that I had to
set aside specific time to “do therapy” with my son.

Or did I?

It wasn’t long before I learned that my world is my son’s oyster of listening and spoken language opportunities.

My auditory-verbal therapist emphasized that my son’s world (e.g. home, car, grocery store, apple orchard, etc.) is the most natural place for him to learn spoken language through listening.

I was reminded that my husband, my daughter and Noah’s twin brother are Noah’s primary spoken language models. I learned that we, as a family unit, know my son’s skills and interest the best.

The Auditory-verbal therapist taught me how to elicit a response from Noah. I learned to wait, pause and to allow him time for him to process the information he heard and to answer for himself. The therapist guided me though typical developmental norms in listening and spoken language and with her help I learned what Noah needed to learn each week. It was up to me to teach him what he needed to learn.

I quickly learned that it’s not practical or convenient (nor is it natural) to have a specific time during each day to “do therapy.” I learned that I didn’t need a therapy room in my house. I learned that every waking hour consists of golden opportunities that will enable my son to develop listening and spoken communication skills. Every hour of every day in the life of our family became the “real therapy session” as opposed to the therapy session in the therapist’s office or our living room.

The “real therapy session” involved anything and everything.
My husband and I could do it any time, any place. It was easy to
involve our other children in the activities we planned.
We quickly saw that all three of our children benefitted, not just Noah.

When my boys were very little I used to walk them around our neighbourhood and narrate as I walked. I would comment on the trees, the weather, the birds, cars, airplanes, anything I saw that I could talk about and point out to them. When the weather was cold, I took them to a local mall and did the same thing. I became very good at narrating while I folded laundry and cleaned the kitchen. Narrating mundane tasks is therapy. It is real life language. Any opportunity to hear rich language was one I took advantage of.

We went to the library almost every day. I found that the more books that I read, the better Noah’s attention span became. Initially, Noah was only able to listen for just a minute or two. Now at six years of age, he is a bookworm whose appetite for listening to a story seems endless.

Not only did children’s books provide the perfect opportunity for
grandparents and other family members to bond together with Noah,
but they also served as conversational starters.

Reading another copy of the book that was introduced by our therapist during her therapy session was also something I did repeatedly. For example, Noah and I read “The Carrot Seed” at home after it was introduced during a therapy session. We then bought carrot seeds and planted them in our garden and watched them grow. We bought carrots at the grocery store and peeled and chopped them in the kitchen. We ate carrots for lunch and dinner. We even baked with carrots. The therapy session was the springboard to the real language experience that happened in Noah’s everyday environment.

I learned to make homemade “experience books” which became great conversational starters. They weren’t anything fancy as I’m far from being a crafty mom, but they were quickly assembled books that contained stories, drawings about events, photos and things that were of high interest to Noah. Repeated exposure to the experience books not only helped my son to improve his speech clarity, expressive language, early literacy skills, but they also gave my extended family members a chance to understand his early communication and literacy attempts.

Noah's AVT space

Grocery shopping and cooking were full of listening and language learning opportunities. I had to shop and cook anyway! It was tailored to any topic or session target being worked on and was modified at varying ages and stages. When my kids were in high chairs, I used to narrate while cooking. When they were a little older, I would have them find certain foods (colours, shapes, food groups, etc) at the grocery store or the kitchen cupboard. I had Noah and his siblings measure, sort, and put ingredients together. The possibilities are endless when it comes to food and language!

Even today at six years old, Noah is always my first child to ask to help me in the kitchen. But now he is the one narrating to me. He is the one reading the recipe aloud step by step. He is the one commenting on how delicious the ingredients smell, describing how a particular food feels in his hands, how excited he is to taste the final result, and making suggestions of what we should cook next time.

Developing skills that will help integrate listening into the
personality of a child with hearing loss does not happen solely
in a therapy session. It does not require a therapy room in the house,
fancy equipment or a even crafty mom.

I have learned that what is required is an open mind and heart, a willingness to explore the world through your child’s eyes and ears with your knowledge and skills learned from the weekly auditory-verbal therapy sessions.

Resources: Cochlear Implants Online


We appreciate your interest in this blog post. The text contained in it is copyrighted by SoundIntuition as of the date of publishing. Contact us by leaving a comment on this post if you would like to use this text elsewhere. When used, we would ask that you cite this page, using the full URL (…om-in-my-house), as being the originator of the content.

Importance of Relationship between Audiologists and AVTs

Stacey Lim bio


No man is an island,
Entire of itself,
Every man is a piece of the continent,
A part of the main.

-John Donne

Although it goes without saying that an auditory-verbal therapist (AVT) and the family are integral components of a child’s spoken language development, the Audiologist also plays an important role.  Audiologists fulfill the auditory needs of the child by providing ongoing audiological assessments, ensuring the use of appropriate hearing aids and/or cochlear implants and FM systems.  These fall within the scope of audiology practice, as well as the guiding principles of auditory-verbal therapy.

Working with an auditory-verbal family and AVT requires the
development of a symbiotic relationship that promotes
the child’s spoken language development.

As an auditory-verbal graduate, I have been fortunate to benefit from the relationship between my Audiologist and my AVTs, who worked closely with each other and with my parents to create the best kind of opportunities for me to learn spoken language.   As an Audiologist, I have been fortunate to have been in environments where the development of a relationship with Speech-language pathologists and AVTs not only is possible, but also encouraged. As a graduate audiology student, I had the opportunity to work closely with the AV clinic at my graduate institution.

First, in the therapy sessions with my fellow speech-language pathology classmates, I was also providing auditory-verbal/auditory-based habilitation, with a stronger focus on auditory skills development.

Second, during my audiology practicum clinic assignments, we shared information from the sessions with the child’s AV clinicians.  If the child’s graduate SLP clinician was available to come to the audiological evaluation, it was not just welcome, but also encouraged.  Through this relationship and inclusion in each other’s professional domains, we could see the relationship between access to sound and language/speech development.

It is these personal and professional experiences that lead me to the conclusion that having an Audiologist on the AV team is highly beneficial.


One of the key relationships in auditory-verbal practice is the one developed between the Audiologist and the AVT. The AVT will see the child on a very regular, frequent basis, such as weekly or even more, while the Audiologist may only see the child once a year or several times a year. The AVT can closely monitor the child’s auditory development and any changes in the child’s listening abilities during the AV sessions. If the AVT notices a change in the child’s perception of sound or speech production, one of the potential causes of this change in speech production or perception could be a change in auditory access.  Ideally, the AVT would recommend that the family make an appointment with the child’s Audiologist.

Prior to the child’s audiological appointment, the AVT can provide the Audiologist with a list of phonemes or sounds that are being misinterpreted or are no longer being produced clearly.  Armed with this information, the Audiologist can check the child’s hearing aids, reprogram them, or if the child is a cochlear implant user, re-map the child. All these would go toward the goal of ensuring that the child has full access to those phonemes.

Further, to ensure that the AVT and child’s caregivers know what access the child has to sound, the Audiologist can provide these partners in the child’s auditory development with the results of the audiological evaluation, hearing aid programming sessions, or cochlear implant mapping session.

By sharing this information with each other, the AVT and the Audiologist ensure that the child’s auditory skills and language development will continue to grow.

Not only do the Audiologist’s roles include the optimization of auditory devices and ongoing assessments, but also includes working with the family and the AVT to promote emerging auditory skills that carry-over into daily life. For example, telephone usage is one of the most challenging activities for individuals with hearing loss. In addition, ensuring that the child’s hearing aids or cochlear implant devices are compatible with the chosen telephone option, the Audiologist can work with the family and AVT to select appropriate telephone accessories, such as amplifiers or cords that connect the phone to the hearing aid/cochlear implant, etc. The Audiologist and AVT can also work together to ensure that these telephone accessories are appropriate and that the child’s hearing devices are effective for telephone use. The AVT could, for example, incorporate telephone practice into the auditory-verbal session, and provide the Audiologist with information about how the child was able to communicate on the telephone.

Working together, the Audiologist and AVT become partners and
combine technology and practice to maximize the child’s

listening abilities in different situations.

This is by no means the only way that Audiologists and AVTs can have a relationship that fosters the child’s development.

One of the other principles of auditory-verbal practice is also mainstreaming in a regular education classroom.  Again, providing appropriate auditory access to educational material is important for language learning, as well as expanding world knowledge. The Audiologist can work with the auditory-verbal family to ensure that appropriate assistive technology (e.g., FM systems) are being used in the classroom.

Moreover, the Audiologist can work with the child’s school to make sure that the FM system is being used correctly by their teachers. The Audiologist can also provide in-service training to educate the child’s teachers about hearing aids, cochlear implants, FM systems, and the importance of auditory access in the educational environment, as well as be a part of the child’s IEP team.

As a guide through the child’s landscape of listening, the Audiologist can work with both the family and the AVT to navigate the intricacies of auditory skills, auditory perception, and hearing technologies.

Working closely with the AVT and the child’s caregivers allows the
Audiologists to see the child’s developmental milestones,

as well as the needs of both the child and the family.

Because hearing and auditory access are such critical components of auditory-verbal practice, the Audiologist is a part of the “continent” of auditory-verbal life.

We appreciate your interest in this blog post. The text contained in it is copyrighted by SoundIntuition as of the date of publishing. Contact us by leaving a comment on this post if you would like to use this text elsewhere. When used, we would ask that you cite this page, using the full URL (, as being the originator of the content.