Category Archives: Audio-Logic

Audiology related blog.

Hearing Screenings for Home birth Babies

Shannon Palmer

Imagine a family anxiously anticipating the birth of their child. Mom gives birth to a healthy baby girl in a hospital in Michigan. Michigan is a state that has implemented universal newborn hearing screening. The baby’s hearing is screened and they are immediately referred to an audiologist. Hearing tests reveal that the baby has a permanent hearing loss. The baby is fit with hearing aids and the family is enrolled in an early intervention program to help the baby learn to listen, understand and use spoken language.

For many parents of children born with hearing loss, this is a common scenario due to the ability to identify children with hearing loss at a young age that is made possible by universal newborn hearing screening.

According to the Joint Committee on Infant Hearing (2007), when a baby with permanent hearing  is identified and enrolled in an early intervention program by 6 months of age, that baby will have the potential to develop age appropriate listening and spoken language skills. For this reason, universal newborn hearing screening programs have been implemented in all 50 states of the United States and early intervention is a reality for many children born with hearing loss. However, there is a population of children who are routinely missing out on this opportunity—children born at home.

Families choose home births for many reasons: proximity to a hospital, religious reasons, a desire for limited medical interventions, or cultural reasons. Unfortunately, these families often face obstacles when trying to obtain a newborn hearing screening for their babies and, therefore, do not get a hearing screening (American Academy of Pediatrics (2011). The obstacles faced by home birth families are often specific to the population of home birth families and the region where they live. In discussion of potential obstacles with home birth families in MI, several common barriers arose.

The first obstacle is simply making and getting to an appointment at a hospital or clinic for the screening. It may be difficult or inconvenient to travel to an outside appointment shortly after the birth of a baby. This is especially true for Amish families who must arrange a ride from someone in their community to travel to the nearest audiology facility. The family may also prefer to avoid hospitals or other medical offices to prevent exposure of their baby to those environments.

Families may also encounter a financial barrier when trying to get a hearing screening for their baby. When a baby is born in a hospital, the cost of the newborn hearing screening is often bundled in with the other services provided and covered by their insurance coverage. If it is not bundled with routine infant care, insurance may or may not cover the cost. Outpatient hearing screening can often result in a higher charge to the parent. Paying for this testing, out of pocket, may not be feasible or be deemed unimportant for many home birth families.

Midwives who attend home-births and provide routine care to these families are in a unique position to help overcome these barriers and obstacles. Midwives are trained healthcare providers who have an expertise in prenatal care, natural childbirth, and postpartum care. They provide care for mothers and their babies, often in the family’s home. It has been concluded that training midwives to complete newborn hearing screening would remove the barriers of time and travel. Further, if midwives were to include the cost of the hearing screening in the price of their services, the financial barrier would be reduced as well.

Unfortunately, most midwives have not been previously trained in how to complete this type of testing and they, typically, do not own the equipment necessary to do a hearing screening. The cost of an automated auditory brainstem response (AABR) unit can be up to $15,000USD and most home birth midwives would not be able to afford this equipment on their own. In the state of Michigan, efforts have been underway making important changes, to ensure that this becomes standard procedure independent of where births take place.

Nan Asher, from the Michigan Early Hearing Detection and Intervention Program, Wendy Switalski from Audiology Systems, and I have been working together to provide AABR equipment to midwives across the state of Michigan. Funded by a grant from the Carls Foundation through the Michigan Coalition for Deaf, Hard of Hearing, and DeafBlind People, fifteen AABR units have been purchased and distributed them around the state. Midwives who will be using this equipment have completed an online newborn hearing screening training module and have received hands-on training with the screening equipment. The training module was created by the MI Early Hearing Detection and Intervention program for all providers who will be completing newborn hearing screening. This module covers information about hearing and hearing loss, risk factors for hearing loss, the type of screening tests that are done, and how to complete and report the results of the screening. The midwives completed this online training on their own time before attending a hands-on training session. The hands-on sessions showed the midwives how to use the equipment, how to report the screening results, and what to tell parents about the results of the screening. Midwives were then able to complete a practice screening using the equipment and a baby doll with a simulated hearing loss.

A baby having their infant hearing screening done by a midwife. (photo: Martin Lux)

A baby having their infant hearing screening done by a midwife. (photo: Martin Lux)

Each AABR unit was given to a midwife or birthing center in a different region of the state and the equipment is being shared among all midwives in that area who have completed both phases of the training. The equipment was distributed based on need — areas with busier midwives received more AABR units. Generally, areas with more the 5-6 midwives or more than 2-3 midwifery practices were considered busy. Annual calibration and refresher training will be provided to make sure that all equipment is functioning correctly, and any problems or questions from the midwives can be answered.

So far, this project has been very successful: 50 midwives*, doulas, and midwifery students have completed the entire training process. Prior to the implementation of these training sessions and equipment, only 19% of home birth babies in Michigan were getting a hearing screening. As of September 2014, that number has increased to 66% — a huge increase! Although we would like to get the number closer to what is seen in hospital births (97% in Michigan), this has been a great start. The midwives we have talked to have been very interested and supportive. They have reported that many of the families they work with have also been open and enthusiastic about having their babies screened.

Typically, Michigan midwives complete the initial hearing screening at their 1 week check-up appointment and if the baby refers in either or both ears, they are re-screened at a subsequent visit. This allows the midwives to meet the Early Hearing Detection and Intervention Program’s goal of completing the newborn hearing screening by one month of age. Babies that refer in either or both ears on the re-screen are referred to an audiologist in their community for a diagnostic auditory brainstem response (ABR) test.

A similar project has been conducted in the state of Utah. From 2007-2013 Utah purchased 23 Otoacoustic Emissions (OAE) screening units and distributed them to midwives in their state. Following implementation of their program the rate of newborn hearing screening for out of hospital births has increased from 2.5% in 1999 to 80.6% in 2013 (Smith, S., Wnek, S., & Badger, K., 2015).

The success of both the Michigan and Utah programs demonstrate several important things.

  1. Many midwives are open to the idea of performing hearing screenings for their clients — Many of the midwives that participated in the Michigan project expressed excitement about being able to provide a service that is routinely offered in a hospital, in the comfort of a family’s own home. Midwives want to provide the best possible care for their clients and by conducting hearing screenings they are able to provide truly comprehensive postnatal care.
  2. Home birth families are open to the idea of having their baby’s hearing screened — Families that choose a home birth are not always opposed to traditional medical care. Regardless of the reason for choosing a home birth, these parents want the best possible care for their babies.
  3. Providing the hearing screening in the family’s home or at a local midwife’s office overcomes many of the barriers of travel or aversion to hospitals — Training and providing midwives with the needed equipment allows them to conveniently conduct hearing screenings as part of their routine follow-up care. Families will no longer be required to make a separate trip to complete the hearing screening.

So what can you do in your own community?

  1. Contact your local midwives. Talk to them about their needs, level of interest in performing hearing screenings, barriers in place for their clients, etc. This will give you a good idea of the current situation that they are facing. Find out if there are other ways to overcome some of the obstacles. These solutions could include some educational materials for midwives and their clients, a better referral process for a hearing screening or transportation assistance.
  2. Identify some funding agencies that would be interested in providing hearing screening equipment to midwives and find out what their requirements are to obtain funding.
  3. Gain a good understanding of the current climate in your area you may be able to come up with some creative solutions that will make a difference.

Before the implementation of universal newborn hearing screening, the average age of identification for children with hearing loss was two years old meaning that children born with hearing loss missed out on two years of sound. This can have a profound impact on speech and language development. Hospital-based newborn hearing screening programs, have brought the average age of identification to six months. The implementation of newborn hearing screening program for home birth babies can allow children born at home to take advantage of the same opportunities provided to children born in a hospital.


* Midwives are not licensed in the state of Michigan

Reference: American Academy of Pediatrics [AAP] (Feb, 2011). Reducing Lost to Follow-Up Rates in Out-Of-Hospital Birth Populations.  EHDI E-Mail Express. Accessed November 15, 2014.

Smith, S., Wnek, S., & Badger, K. (2015). Out of hospital midwives: Improving compliance with hearing screening in Utah. The National Early Hearing Detection & Intervention Meeting. Louisville, KY.

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.

Why audiologists should care about the ten principles of LSLS Auditory-Verbal Therapy

Stacey Lim bio

As an individual who has been a recipient of auditory-verbal therapy, I consider myself fortunate to have had an excellent paediatric audiologist who provided my parents – and me – with knowledge about hearing loss, hearing technology, and how to develop spoken language skills. As I’ve joined the audiology profession, I have reflected on the guiding principles of auditory-verbal practice and what role audiologists can play as they serve auditory-verbal families. It is not only the auditory-verbal therapist who can follow these guidelines, but also other professionals, such as audiologists. I firmly believe that by supporting an auditory-verbal family, we have a large role to play in the child’s development and growth, and by incorporating the auditory-verbal principles into our practice, we can ensure that we are providing the services the child needs.

The ten principles of auditory verbal practice are highlighted below, and how I have incorporated them into my practice and philosophy as an audiologist.

1. Promote early diagnosis of hearing loss in newborns, infants, toddlers, and young children, followed by immediate audiologic management and Auditory-Verbal therapy.

A goal in audiology is to ensure that hearing loss is identified early.  Today’s universal newborn hearing screening programs allow audiologists to determine which infants need to have follow-up audiological assessments.  According to the Joint Committee on Infant Hearing (in the United States), hearing loss would be identified within three months of the newborn hearing screening.  Early identification in infancy allows the child to have the opportunity to develop age-appropriate language skills, when hearing loss is managed through amplification and a spoken language program such as auditory-verbal therapy.  With early diagnosis, amplification, and intervention, it is possible for children with significant hearing loss to develop age-appropriate language skills. As audiologists, we can provide our families with information about early intervention services, and why it is important to have early intervention services—that we need to get information and language to the child’s brain as early as possible.

Not only can hearing loss be present at birth, but hearing loss can occur later in childhood. Some children may have progressive hearing loss, or hearing loss that worsens over time. Hearing loss is not always present at birth, and as audiologists, we can work with physicians or other health care and educational professionals to educate them about the importance of early identification of hearing loss.   By identifying later onset hearing loss in toddlers and children, we can then move toward appropriate intervention of hearing loss. In doing so, we can ensure that they do not lose any language learning opportunities.

2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation.

A key point in auditory-verbal practice is the use of appropriate hearing technology that provides the child with the fullest possible range of speech sounds. In addition to fitting the child with hearing aids best suited to their hearing loss, it is also critical to ensure that benefit is being provided through hearing aids, via real-ear measures and behavioural testing in the sound booth. If it is determined that a child is not obtaining benefit from hearing aids, the audiologist should discuss other options, such as cochlear implants, with the child’s caregivers.

In addition to hearing aids and cochlear implants, the audiologist should also recommend the use of FM technology. FM technology allows the child to hear the speaker’s voice as if he or she was next to the child. In this way, the acoustic signal is not lost over distance and can be heard over background noise.  This option can be considered not only for educational environments, but also for use at home or in other surroundings, such as the car or environments where background noise can compete with the parent’s voice.

Appropriate hearing technology is important, not only for making sounds audible, but fitting hearing aids and mapping cochlear implant devices appropriately allows the child to have full access to the spectrum of speech sounds.  This is important for language development, and later literacy development.

3. Guide and coach parents to help their child use hearing as the primary sensory modality in developing listening and spoken language.

Children who have normal hearing have 24/7 access to their hearing. This means that even when they are not actively listening, such as when they are asleep, they are exposed to auditory information. Children with hearing loss have access to sound when they wear their hearing technology. Thus, they do not have 24/7 access to auditory information. Thus, when children are awake, they should be wearing their hearing technology, and parents are the ones who can ensure that their children’s hearing aids or cochlear implants are being worn. If the parent’s desired outcome is for their child to learn spoken language auditorily, they must encourage the use of hearing technology. And not only wear the technology, but highlight the auditory information that is being accessed. As audiologists, we can stress the importance of exposing the child to auditory information, because it is how children will acquire their knowledge of language and the world.

4. Guide and coach parents to become the primary facilitators of their child’s listening and spoken language development through active consistent participation in individualized Auditory-Verbal therapy.

The child spends up to a few hours a week with the auditory-verbal therapist, perhaps 30-40 hours a week with teachers, and the majority of his or her week with parents or primary guardians.  Thus, parents are truly the language models for children.  Parents, then, are the ones who may have the greatest amount of responsibility, not only for ensuring that hearing aids and cochlear implants are working correctly, but also for facilitating auditory learning.  In conjunction with the auditory-verbal therapist, the audiologist can work with the parent to develop individualized tools and strategies to emphasize auditory learning and development.

5. Guide and coach parents to create environments that support listening for the acquisition of spoken language throughout the child’s daily activities.

Children’s brains are developing skills, such as top-down processing or filling in the gaps in information that is missed during conversation.  These are skills that adults have, as a result of years of practice listening and communicating.  Because children are developing these skills as they acquire language, they require environments to be optimal for language learning. There are several things parents can do. One is for parents to speak at a clear, slower pace with a melodic voice. Children will “hear” that information better. Other adaptations parents can make is to the physical environment, by making it acoustically optimal for language learning. Parents can make sure that there is less background noise present during conversation. For example, the television should be off or at a quiet level (if someone else is watching it) when the parent and child are interacting with one another.

Warren Estabrooks reviewing the auditory-verbal principles with some students

Warren Estabrooks reviews the ten principles of LSLS Auditory-Verbal Therapy

6. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child’s life.

Again, children with normal hearing have access to auditory information 24/7, and children who use hearing technology have access to auditory information only when they are wearing and using hearing technology.  Thus, audiologists have to educate the parents about the importance of providing information and knowledge about the world to the child’s brain through their ears.  During all waking hours, the child should be wearing hearing aids, cochlear implants, and FM system so they have access to sound and spoken language.  Not only should the child be wearing hearing aids, but the parents should also provide auditory input in the form of complete, complex sentences. Other auditory activities can also include reading out loud with the child and singing with the child. These activities of conversing, narrating, reading, and singing will help the child’s brain develop listening skills and knowledge about the world.

7. Guide and coach parents to use natural developmental patterns of audition, speech, language, cognition, and communication.

Our role as audiologists run deeper than simply telling the parents about the thresholds that were obtained on the audiogram.  While it is important for parents to understand the X’s and O’s on the audiogram, what is even more important is for the parent to understand the critical importance of accessing the child’s brain and providing knowledge to the child’s brain. It is not just sound, but all the meaningful aspects of sound that we want to provide through hearing aids, cochlear implants, and FM systems. In order for that knowledge to become a part of that child’s personality, the parents need to provide the child with a rich, complex language base. This means reading every single word in books. Not only reading, but also having conversations about the book, the characters, motivation to build cognitive and linguistic skills. Another way to build language and vocabulary knowledge is to have conversations about the daily activities. It is also important for the parent to communicate with the child in complete sentences, not short, monosyllabic words or short phrases.

8. Guide and coach parents to help their child self-monitor spoken language through listening.

While parents can – and do – play a role in monitoring their child’s spoken language output and auditory skills, it is also important for the child to develop skills to independently monitor their own understanding of spoken language and their own language productions. The child, who has a strong focus in listening, can learn to assess their own understanding of what is being said around them. Parents can help by modeling or demonstrating good listening behaviors and clarification strategies. Children should also be involved in their audiology appointments, even listening to the audiologist explain hearing technologies, how they work, listening to descriptions of their audiograms and the test results. Making sure children have a complete understanding of their hearing loss gives them ownership of their hearing loss. By having a greater ownership of their hearing loss, they can develop advocacy skills, which are necessary when they are in situations (such as noisy environments) when it is more difficult to understand spoken language. This, of course, is a skill that is built over time, but it is a good skill to develop early, so it becomes natural for the child to independently self-monitor their own access to auditory information at an early age.

9. Administer ongoing formal and informal diagnostic assessments to develop individualized Auditory-Verbal treatment plans, to monitor progress and to evaluate the effectiveness of the plans for the child and family.

As audiologists, our scope of practice includes diagnostic audiological assessments to evaluate our client’s hearing status. What we can do for the auditory-verbal child is to assess not only the unaided thresholds, but also aided/cochlear implant thresholds at varying intensity levels (soft, average, and loud conversational levels). We can also assess the child’s speech understanding ability not only in quiet, but also in noise. These are important for several reasons: administering audiological assessments on an ongoing, regular basis allows us to determine whether there has been any change in hearing status. If there is a change in hearing ability, we can use this information to make the appropriate adjustments to the child’s hearing technology or recommend more appropriate hearing technology.

10. Promote education in regular schools with peers who have typical hearing and with appropriate services from early childhood onwards.

A major goal of auditory-verbal practice is for the child to be in the mainstream educational environment. This means that children will be in classrooms with normally hearing children who are their peers. However, classrooms are noisy environments, and in order to keep up with material presented in class, the child with hearing loss will need accommodations to ensure that they have full access to information.  An audiologist’s role in this case may include being involved on the child’s IEP team and working with the school to determine the types of accommodations that may be necessary for the child’s success in the educational environment. Some accommodations may include an FM system, acoustically treating the classroom, a buddy system, textbooks for the parents to use at home to reinforce the concepts in class or to pre-teach unfamiliar vocabulary, among many other possible accommodations.  It is incredibly important to have a working relationship with the other professionals who work with the child. By having this open communication about the child’s progress in school or in auditory-verbal therapy, we can ensure that the child continues to progress at an age-appropriate level.

In understanding all ten principles, and incorporating them into professional practice, we can be certain that we are providing the best services possible to an auditory-verbal family.  We have a role in developing the child’s brain and access to the world.  This concept of helping the child’s brain grow is a motivation for what I do and how I approach my practice as an audiologist.

*An Auditory-Verbal Practice requires all 10 principles.


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.

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. 

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:

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.


Hearing Heroes

Carrie Spangler

I am honored to be asked to write the first blog post for the Audio-Logic blog.  As I was thinking of an appropriate topic, my mind went directly to Karen, the owner and founder of SoundIntuition and how I met this wonderful person.

I met Karen for the first time she was a graduate student in audiology, and it was life changing for me!  This life changing event is supported by the Supplement to the Joint Committee on Infant Hearing 2007 Position Statement:  Principles and Guidelines for Early Intervention Goal 11 which supports that all children who are deaf/hard of hearing and their families have access to support, mentorship, and guidance from individuals who are deaf/hard of hearing.

Growing up as the only person in my family and my mainstream school with hearing loss posed a challenge at times.  I know that my parents felt alone in the journey, not having any support or what to expect.  I know that I felt that life was not fair that I had to wear hearing aids when seemingly everyone else in the world had nothing in their ears!

Then I met Karen.  I will never forget that day when I was in high school attending an appointment for an annual audiological assessment and she introduced herself as a graduate student in audiology.  She went on to explain that she had a hearing loss like me and wore hearing aids (now she wears cochlear implants) and uses a personal FM system.  I remember thinking….”Incredible!  This beautiful young adult studying to be an audiologist, AND wears hearing aids just like me!”.  This day was a pivot point for me.  I realized that I could be at peace with my hearing loss and make a choice to change my attitude about hearing loss.  I realized that hearing loss was a positive asset and would be one of the greatest gifts that I could have.

The American Speech-Language Hearing Association’s Joint Committee on Infant Hearing (JCIH) Goal 11 states that “families who have many contacts with adults who are D/HH exhibit a strong sense of competence with regard to raising their child who is D/HH”.  Audio-Logic “ally” speaking, I would expand to say that children and teens that have contacts with mentors who have hearing loss exhibit a strong sense of competence with regard to themselves.

I am thankful that Karen and I share audiology as a career path, which has allowed us to reconnect both personally and professionally.  However, there was a long period between the first time I met Karen and the next.  With that being said; this ONE meeting can leave a positive imprint on individual with hearing loss, especially a tween or teen-ager that may be dealing with self image and fitting in.

Carrie's Group

As a professional working with individuals with hearing loss or a parent who has a child with hearing loss….what can you do?  You could make the “pivot point” happen for that important tween or teen.   When I began my first year working as an educational audiologist for Stark County Educational Service Center (Canton, Ohio USA) I made the decision that I wanted to be able to offer this “pivot point” for students with hearing loss in the mainstream.  I had vision that every student that I worked with should have the opportunity to meet another student with hearing loss before graduating.  I began to share my vision with colleagues and the idea of a support group called Hit It! (Hearing Impaired Teens Interacting Together) was born.  When I had this vision in my head, it was no longer the question of “should I do this?” it became “how can I do this?.  When you ask “how?” ideas start developing and action begin to take place.  Our first Hit It! meeting took place in 1999 and has been going strong since.  We have been connecting students with hearing loss, hoping to move their “pivot point” positively.

Starting a support group seem overwhelming?  I know how you feel!  I am now in a new position at The University of Akron and starting over.  To get started, I reflect back on the “pivot point” of meeting Karen for the first time in my own life and realize that I want to positively influence the lives of teens with hearing loss wherever I am.  I am now asking “how?” and talking to colleagues.  As professionals working with children with hearing loss, we have tremendous influence and connections.  Still overwhelmed?   Think about starting small and connecting families and children with hearing loss for a 2 hour event.  Or strategically schedule patients and families back to back that you think would benefit from meeting. Creatively act and you will be rewarded knowing that you have made a difference!

As I wrap up this blog entry, I encourage every professional and parent to CONNECT children with hearing loss with others who can be a positive “Hearing Loss Hero” in their 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.