Category Archives: I Hear That

What comes first? Short-term Objectives or the Toy?

Karen MacIver-Lux

I’m a toy enthusiast. Luckily for me, as an auditory-verbal practitioner, toys are the tools of my trade and I can share my love of toys with the children I work with and their families.

I have to admit, however, that toys have gotten me into trouble at times. Not trouble of the financial kind; the goal setting kind.

In other words, I have sacrificed appropriately set goals (short-term objectives) because I loved the toy and stubbornly thought that I could make it work for the child and parents/caregivers (family). The trouble was that short-term objectives ended up being adjusted to suit the toy or theme and not the child, resulting in an activity that was either too easy, too hard or not relevant to the child and family’s culture, interests or daily routines. 

As you can imagine, the child was forced into an unfair situation and responded accordingly (e.g. crying, refusal to engage in play, etc.), and the family went home with unrealistic expectations of the child (e.g. inappropriate short-term objectives), and both the child and the family began to lose confidence in their therapy experience.

One of the toughest lessons I had to learn early on in my career were:

  1. Appropriately selected short-term objectives primarily guide the toy/theme selection process.
  2. The child’s interests and family’s environment, culture and daily routines play a supporting role in the toy/theme selection process.
  3. The primary purpose of the session is to guide and coach parents/caregivers/family members in ways to play so that learning opportunities in listening, spoken language, critical thinking, and literacy development are bountiful. The toy/theme is a tool, to be used as a means to an end.

Many therapists would state that they can apply appropriately selected targets to any toy or theme. That may be true in some cases, but I find that I only do this during the session when short-term objectives have been adjusted due to changes in the child’s listening and spoken language abilities, or if the child has brought in his/her toys from home for “show and tell.” The mark of an effective therapist is one who plans well and is prepared to adjust to changes in the original plan.

Toy Montage

Selecting short-term objectives

As a rule, short-term objectives are planned before choosing the toy for the following reasons:

  1. Some toys and themes are better than others at fulfilling all of the short-term objective and engaging the child’s interests. Therapists owe it to the families to choose the toy (or theme of play) that addresses all of the child’s short-term objectives within the time frame of the therapy session. In order to do this, the therapist needs to know what the short-term objectives are first.
  2. When families don’t own the same toys at home that the therapists used, they may feel the need to go out and buy the same toy so that they can do the homework required. Therapists need to guide families in learning how the short-term objectives (homework) can be incorporated into the child’s daily environment, routines and play activities. At the end of each session, the therapist and parent should review the short-term objectives. Asking, “How do you think you can help [name of child] learn to understand and use [short-term objective] within their environment (or playtime with their toys)?” helps parents plan ways that they can create meaningful, age- and stage-appropriate listening and spoken language learning opportunities for their children daily.
  3. Short-term objectives often influence which strategies are going to be used by the therapist to facilitate ease of learning. For example, a short-term objective for a child who has a high frequency hearing loss might be to “demonstrate understanding of morphological marker for plurals( -s).” The therapist must be prepared to check the hearing technology (e.g. hearing aid and personal FM system) to ensure that the child has auditory access to “s”. The therapist determines which strategies would make the “s” acoustically salient to the child, using techniques such as whispering the target word or elongating the “s” sound. The therapist must be prepared to explain why these strategies were used and when to use them during daily routines. When the family gains understanding of, and proficient use of, these strategies, the child will gain improved access to the listening and spoken language opportunities that naturally occur during the family’s daily routines and environment.

Weekly, I challenge myself by picking short-term objectives for various age groups (1, 2, and 3 year olds) and choosing toys or themes that are best suited for each age group. I then think about how I can use these toys to accomplish my short-term objectives.  I often consider the culture and interests of the children and families on my caseload and assess the appropriateness of the toys/themes chosen. I recall strategies that, when used, make the short-term objectives in listening and spoken language easier to hear, learn, say, read and write. This is usually done as a mental or an exercise/conversation with colleagues.

By firstly becoming a short-term objective enthusiast and a toy enthusiast second, I am better able to focus on providing the best quality intervention I can, in hopes that I can help the child and family meet their long-term goals in an timely manner.  By prioritizing short-term objectives I have found that I have become more confident in my practice as an auditory-verbal practitioner.

So, take a moment and reflect. Are you a toy enthusiast or a short-term objective enthusiast? We would love to hear from you!

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 You T.H.I.N.K When Providing Intervention?

Karen MacIver-Lux

Auditory-verbal therapists spend a lot of time coaching, providing feedback and engaging in collaborative discussions with parents. Speech-language pathologists, audiologists, teachers and other early intervention professionals (professionals) are no exception. Effective communication is recognized as a priority across the health care continuum because it directly affects the quality of patient care, safety, medi-care outcomes and patient satisfaction (1995).

Occasionally, professionals may need to deliver news or feedback that can difficult for a parent/child (client) to hear. Some professionals dread having these conversations because, despite their best intentions, the information gets lost in translation and clients can end up feeling unnecessarily frustrated, discouraged or even angry. As a result, rather than putting into action a plan for care, valuable time can be spent recovering from the shock of the news.

In her book The Now Impact, Elisha Goldstein describes the T.H.I.N.K. strategy, which can be used when preparing to provide feedback or information so that the message is clear and concise. This strategy can also be used when communicating and engaging with young clients, particularly during behavior management.

Before engaging and communicating with clients, it is a good idea to T.H.I.N.K. by asking ourselves if what we’re about to do or say is:


When discussing treatment plans/options, try to ensure that the information shared is accurate and current. When sharing observations, try to accurately describe what was observed, remembering to include multiple examples/evidence. When the answer is unknown or unclear, say so. Then work together with the client to find the answers. If the client requests additional information about a topic or intervention approach we’re not familiar with, refer them to the appropriate source(s) or professional(s).

During my years working with children, I’ve learned to say what I mean and mean what I say. Body language and follow-through are as equally important as the message.  If I say I’m going to do something, I need to do it.  When working with clients, I need to walk the talk, truthfully.

Many years ago, I saw Jack (not his real name), an adorable three year-old boy who noticed every delicate décor accessory in the clinic. Jack would have these in his hands before his mother or I can move them out of reach.  One day, he looked at a flower vase, and reached out to touch it.  I smiled cheerily and said in the nicest voice I could muster, “No, no, Jack. Don’t touch the vase! If you touch it, it will break!” Well, guess what? Jack touched the vase and it didn’t break. My voice and body language did not match the message and the verbal consequences I presented didn’t make sense. Nor was it the truth.

The next time Jack walked by the vase, he reached out to touch it and looked back at me. This time, I didn’t smile and I used a quiet but firm voice and said, “No, Jack. Don’t touch the vase. If you touch the vase, I won’t be happy and there will be no bubbles.” He touched the vase, so we didn’t play with the bubbles during our session.

The next time Jack walked by the flower vase, he didn’t touch it and as a result the beloved bubbles stayed in our session plan. My body language matched the clear boundaries I set and the consequences were realistic and truthful.


As professionals, we are accustomed to providing recommendations and suggestions and we expect the children and their parents to follow them. At times, however, due to a family’s circumstances, the recommendations may be easier said than done.

Consider the following case of a family whose baby, Molly, was fitted behind-the-ear hearing aids one month prior. During their follow-up visit with the audiologist, the parents reported that Molly had adjusted well to the hearing aids and is wearing then during all waking hours. Upon reviewing the data logging, however, the audiologist noticed a discrepancy that suggested that the hearing aids were only being used four hours a day.

Although tempted to question the parents about the discrepancy, the audiologist refrained. Instead he said, “I see that your baby is getting an average of four hours a day of hearing aid use.  This is a great start!  Our goal is to have the hearing aids on during all waking hours. How do you think we can achieve this goal with Molly? Is there anything I can do to help?” The parents showed surprise and responded that they are certain that the hearing aids are being used at all times except during rides in the car, bath time and sleep .

After the audiologist waited for a few minutes allowing time for self reflection, the parents suggested the possibility of the hearing aids not being used while Molly was at daycare. Later that evening, the parents discovered that the daycare staff were uncomfortable handling the hearing aids and were fearful of losing or breaking them. In addition, the other children were pulling Molly’s hearing aids off and placing them in their mouth. As a result, fearful for all the children’s safety, the staff weren’t always diligent in putting the hearing aids back on.

With this information at hand, the audiologist and the parents developed a plan of action to help ensure that the hearing aids would be worn during the baby’s entire time at daycare (e.g. a pilot cap and an in-service for the staff on the handling and care of the Molly’s hearing aids). Adopting a helpful attitude and supportive language is what often sets the stage for progress.


When I was 13 years of age, I decided that I wanted to become an audiologist.  It did cross my mind, however, that given the severity of my hearing loss the job may be difficult to do. How would I be able to do listening checks on a hearing aid? Was my speech good enough to do speech discriminations tests?

The list of questions grew longer and my dream drifted further and further away until I met Jeff Float.

As team captain in the men’s 4×200-meter freestyle relay, Jeff Float was the first legally deaf athlete from the United States to win an Olympic gold medal. Impressed by his story and example, I realized that if he could start a relay race, then so could I.

Meeting Jeff Float gave me the inspiration to pursue my dreams with dogged determination.

When parents are faced with their child’s diagnosis of a communication challenge, they are usually uncertain of what the future holds. In all honesty, so are the professionals.  Professionals however, have the advantage of having the skill set and knowledge to develop an intervention plan to help the child reach his/her highest communication potential. It’s important for  professionals to remember that parents not only need a plan of action, but that they need some inspiration as well. The same goes for young children, teenagers and adults with communication disorders.

  1. Arrange appointments so that clients have the opportunity to meet other others with similar communication challenges. Partner “new parents” with parents who have been through the process.
  2. Present opportunities for children with communication challenges (e.g. hearing loss, dysfluencies, cerebral palsy, auditory neuropathy spectrum disorder, etc.) to meet adults with similar communication challenges.
  3. Encourage children and young teenagers to join peer support groups of similar communication challenges (e.g. LOFTHitIt, etc.).
  4. Use language that is respectful of other professionals and communities who have embraced alternative communication approaches.

A good dose of inspiration goes a long way for those who have communication challenges and paves the way for the achievement of dreams and beyond. Encourage clients to aspire by introducing them to those who inspire.



When my mother found out about my hearing loss when I was four years old, the doctor firmly told her that I would never hear or be able to speak.  He also added that I would never go beyond grade three, and that I would be severely limited in my vocational choices. He explained that it was necessary for my mother to adjust her expectations of me because of my mild to profound hearing loss. He then left the room to attend to another patient. Did my mother adjust her expectations? No, but she did feel devastated by his words and it took her some time to recover and move forward to find out what I really was capable of.  She later discovered that the doctor not only provided inaccurate information at the time (e.g. I could hear her voice even without hearing aids because I have a mild to profound hearing loss) but I also achieved outcomes beyond his expectations. To this day, my mother remembers his words and is still angered by them. Unfortunately, similar interactions still occur today unnecessarily causing parents grief and aggravation.

Each case is unique and professionals need to gauge the type and amount of information to provide. It is best to avoid making predictions about outcomes. Instead, listen to the parents’ dreams and desired outcomes for their children. Professionals should provide research data on outcomes and variables that can be controlled (e.g. hearing technology). Parents should be directed to resources so that they can do their own research. When parents’ dreams for their children have been heard and understood by professionals, parents will be more open to developing a plan of action in a collaborative fashion and following it.

Be mindful of when and how we share information.  Is it necessary to call a parent on a Friday afternoon to recommend a cochlear implant candidacy investigation when your next appointment with them is on Monday? Is it necessary to tell a parent of a one year old child to work on producing “s’ in words?  Is it necessary to provide parents of a newly diagnosed infant with a thick binder of information on hearing loss?  Is it necessary to tell a child that he’s a good boy when he hears a clock ticking?

When we take the time to consider the necessity of the information we provide to parents and children, chances are they will be more open to listening and moving forward with a plan of action.


Kindness is not just about being polite or generous; it’s also about having and demonstrating empathy.

Unfortunately in today’s world, kindness and empathy are sometimes regarded as signs of weakness. Often, the perception is that kind and empathetic professionals are either too timid to be effective or that they rely on their “niceness” in place of knowledge and the ability to effectively treat or impact clinical outcomes. Additionally, there seems to be a fear among some in the “helping” profession that empathy will lead to “burn out” early in their careers, and they develop a persona of polite indifference to protect their mental health and livelihood.

Clients who engage with professionals who behave with indifference, understandably, lose trust in the professional and their treatment plan, and progress for positive change is disrupted or grinds to a halt (2014).

Kindness and empathy is demonstrated by adopting body language that clearly shows that the professional is truly listening and by providing feedback the professional confirms that the client/patient was heard and understood.

It’s important for the professional to remember, that they need to move quickly from empathy toward developing a plan of action in collaboration with the client/patient.  Such collaboration will lead to the client/patient acquiring greater knowledge, trust, and motivation during the intervention process.

Remember Molly’s audiologist?  Her parents were given the opportunity to take the time to think about why her hearing aids were not being used as often as they thought. How?  Making sure to keep his arms uncrossed and open, leaning forward and providing good eye contact, making sure that his legs are uncrossed as the audiologist waits and allows the parents to self-reflect. Adopting such body language conveys that he is open to hearing whatever they have to say and that he’s open to being helpful.

When planning your next session, celebrate your professional strengths and challenges and T.H.I.N.K. before doing and saying. When we T.H.I.N.K., communication and collaboration will lead to better understanding, collaboration, client satisfaction and outcomes.

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.


Stewart, M. (1995) Effective physician patient communication and health outcomes: a review. Canadian Medical Association Journal. 1995;152(9):1423n1433. 261
Back, A.L. & Arnold, R.M. (2014). “Yes It’s Sad, But What Should I Do?”: Moving from Empathy to Action in Discussing Goals of Care. Journal of Palliative Medicine 17(2):141-4.

Let Your Holiday Toys and Decorations Do The Talking ALL Year Round!

Karen MacIver-Lux

At this time of the year, many people around the world are celebrating different holidays,  some Hanukkah, while others are eagerly anticipating the arrival of a jolly fellow in a red suit on Christmas eve or morning.  Decorations have been put up and gifts are waiting to be opened.

At SoundIntuition, we are using this time to celebrate the toys and decorations of the holiday season, and the professionals and families around the world that are on a journey of turning a grey world of silence into a colourful world of sound.

Wait a minute.  Toys and decorations of the holiday season? Yes. You read that correctly.

Many of us underestimate the power the toys and decorations that come with seasonal holidays like Hanukkah and Christmas, returning the toys and decorations to their storage boxes too soon after the holidays are over. But when we do, we miss out on opportunities for conversations that stimulate brain growth. Brain growth that results in improved listening, spoken communication and literacy skills.

I once kept a Christmas tree up until just before Easter. Yes, I know it’s overkill, but let me tell you, it got a lot of my children and their parents talking and asking questions.

I heard moms and dads croon to their babies using phrases like:

“Look!  Look up, up, up the tree!  There’s a star!  Let’s sing a song about stars!”

“Look!  There’s an ornament!  It goes round and round and round!”

“There’s the light!  Don’t touch it! It might be hot!”

I heard moms and dads help their toddlers and preschoolers learn to follow simple directions and engage in conversation using phrases such as:

“Uh oh, the star fell down! We better pick it up!”

“It’s broken!  Oh no! What happened?”

“Ouch, the tree is prickly. Oh no, do you have a boo boo?”

I heard older children ask their moms and dads questions such as:

“Is that a Happy New Year tree?”

“WHEN IS Auntie Karen gonna take Christmas tree down?”

“Won’t the Easter Bunny wonder if it’s too early to deliver eggs if he sees the Christmas tree?”

More often than not, the conversations included many of my session targets.

Put simply, the Christmas tree gave my families and children something to talk about.

After each holiday season, I run to the craft store and go on a shopping spree.  I take advantage of the sales and purchase more seasonal decorations and toys.  I keep them out all year round because these are the toys that give the most bang for the listening and language-learning buck.

Seasonal Toys


The dreidel is a classic Learning to Listen (LTL) toy.  When using the dreidel, we can talk about it by using phrases, questions and directions that include future, present, and past tenses, predictions, counting/numbers and concepts such as more, again, after, before, etc.  There are many songs that can be sung with the dreidel that can be found in Hear and Listen! Talk and Sing! (Estabrooks, 2006). The language used during play with the dreidel is meaningful, repetitive and most importantly, easy to hear, say and sing.

“If we count to three, we will spin the dreidel and watch it go around and around until it stops!”
“Wanna spin it again?”
“Let’s do some more spinning.”
“Oops, the dreidel went flop!  The dreidel fell down.”
“Pick it up and I’ll help you spin it around again.”
“Okay, get ready to count!”
“Oo, look at it go around and around and around!”
“Before we spin the dreidel again, let’s sing the song.  After we sing the song, we will spin the dreidel.”

Christmas Present/Advent Calendar Toy

This a toy that was meant to be used as an advent calendar.  The gift boxes are decorated in various patterns, colors and numbers.  There is a door that opens to reveal the gifts (tiny toys) that are placed inside.  I like to keep this toy accessible throughout the year as it gives me the opportunity to:

  • ask the children to follow multi-element directions such as:

“There is a toy for you in the purple present with the yellow polka-dots”

“If you add the numbers on the gift that is red with the yellow bow and the gift that is blue with the yellow stars, what number would you get?”

  • ask children to identify items in a box upon hearing descriptions such as:

“There is a fruit that monkeys like to eat in the present that is the same colour as grapes with stripes that are the same color as the sky.”

  • Assess or develop auditory memory skills by asking the child to:

“Give mommy the present with the number 13, and Daddy the present that has the number that goes before 4.”

The above are just a few examples of how an advent calendar can be used once the boxes have been opened.  Decorations and gift boxes can be recycled again and again for the purpose of developing listening and spoken language competence during meaningful and fun contexts.

So, instead of putting away the toys and decorations of the Holiday Season, use them throughout the year.  The repetition of the words, phrases, songs and stories will help our children prepare for the next round of Season’s Greetings, and give them something to talk about!


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.

Birkenshaw-Fleming, E. & Estabrooks, W. (2006)  HEAR AND LISTEN! TALK AND SING, Songs for Young Children who are Deaf or Hard of Hearing and Others Who Need Help in Learning to Talk, 2nd Edition.

The “Say NO to Selection Tasks Challenge”

Karen MacIver-Lux


There’s a good chance that you’ve taken a challenge of some kind.

Everyone loves a challenge, especially when it’s a challenge that leads to something good.

That ‘something good’ could be an extraordinary accomplishment. Like an entry into the World Guinness Book of Records—one mother I worked with pulled a 109,000 lb. train 73 feet and 6 inches with eleven of her cross fit partners in 90 seconds. Or it could be a lifestyle change that will lead to a more fit or healthier body—a daily challenge for me. Or perhaps some fun activity that, when completed, leads to a donation to a charity.

But I’d like to issue a challenge that’s near and dear to my heart.

It’s called the “Say No to Selection Tasks” Challenge.

What is a Selection Task?

A selection task refers to the process of the therapist/parent requesting the child to retrieve one (or more) toys (could also be picture cards) item from a group of toys  (may vary in “set size”) that have been placed in front of the child (in a line or a half circle).  Therapists call this a “closed set” selection task because the set of options is visible to the child. The selection task can be used to assess the child’s skills in areas of audition (e.g. discrimination, auditory memory, etc.), speech (e.g. articulation), language (e.g. receptive/expressive vocabulary, grammatical concepts, etc.), and cognition (e.g. item identification by description) or to teach them those skills.

The Problem With Selection Tasks

As a late identified child with hearing loss and a significant speech and language delay, I was no stranger to selection tasks.  I used to sit in a tiny room at my neighbourhood school, with two other kids (typical hearing with articulation issues) in a group speech-language therapy session. Our speech-language pathologist promised that if we selected the toy she requested, and said its name correctly, we would get a lovely surprise at the end.

There are a few problems that I have with selections tasks.

1. Failure Prone

I’ll never forget the feeling of hot embarrassment that crawled up the back of my neck to my cheeks when I selected the wrong toy. It didn’t matter when the speech-language pathologist said “that’s okay sweetie, good try!” because it’s the feeling of failure that always lingered. Children may not always remember what was said, but they always remember how they felt.  Yes, it is part of life to experience failure, but more often than not, failures in life result in valuable lessons learned.  What is the lesson learned in selecting the wrong toy? I haven’t figured that one out yet.

Bottom line is, as a clinician, I have difficulty asking a child to risk experiencing failure from selection tasks, just so that I can get diagnostic information in a quick and efficient way.

2. Unrealistic 

A lesson using a line-up of toys to teach target words, concepts, and grammatical structures is unrealistic and often fraught with grammatical mistakes and inappropriate pragmatics.  For example, if the session target is for the child to use the words “my” and “your” correctly with toys that don’t even belong to the child and that are placed in a neat and tidy line creates an unrealistic set up.  The therapist would be asking the child to “pretend” that some of the clinic’s toys belong to the child while others do not.  Secondly,  realistically speaking, who lines toys up before playing with them? Usually, kids don’t. Neither do I!

Such inconsistencies create added confusion for the child to sort out, and I would expect learning and generalizing of new vocabulary and words to be more challenging.

Let’s consider a game of Connect Four as an alternative. The therapist and parent/caregiver can demonstrate distributing the chips to the main players (e.g. This yellow chip is your chip.  This red chip is my chip.  This is your chip, and this one is my chip.  Your chip.  My chip.) The therapist and/or parent/caregiver could introduce sabotage (fun!) by stealing the child’s chip (e.g. “No! This yellow chip is my chip, and this red chip is your chip!” This makes better sense to the child, and is grammatically and pragmatically appropriate). This game gives the therapist and parent/caregiver abundant opportunities to expose the child to other words, phrases and grammatical markers that are appropriate and accurately used.

3. Boring

Which of the following picture is more interesting to look at? Which setting would you gravitate to (top or bottom) with a child holding your hand?

Toy lineup

I rest my case.

Are we using Selection Tasks today?

Unfortunately, too many of us are using selection tasks today.  I have done it!  We use selection tasks because it’s a quick and easy method to use so we can assess the child’s current skills an progress in areas of audition, receptive language and cognition.  Today, I see many therapists and parents around the world using selection tasks simply because “we’ve always done it this way.”

I recall many occasions at the Learning to Listen Foundation when my mentor, Warren Estabrooks, challenged himself and the therapists on his team to do away with selection tasks, and incorporate music, literature, play and conversation into the session to raise the bar in listening and spoken language development. He firmly believed that through play, books, songs and conversation, we could gain more accurate diagnostic information while at the same time, creating exciting opportunities for listening and spoken language enrichment. Warren and his staff of therapists shared ideas, tried them out (some failed and some were successful), and saw positive changes in the children and the parents.  We learned to set up therapy sessions so that the child is eager and excited to show us what he/she knows and can do.  When the context is meaningful, enjoyable and conducive to success, listening and communication confidence soars.

Many therapists have learned to say no to selection tasks, choosing rather, to focus more on teaching in a way that feels natural to the child and their parent/caregiver.

I challenge you to incorporate the following session targets into a session using a play scenario, song, book or conversation:

Session Targets:

  • Demonstrate auditory memory for three items.
  • Demonstrate the ability to follow directions that contain four critical elements.
  • Demonstrate the ability to learn a new song/poem that contains four lines of two to four word phrases.
  • Demonstrate understanding of plural –s.

Share it with us via a video (remember to follow privacy laws of your country) or a written description of how the session went,


  • donate to a charity near and dear to your heart, that helps children with communication disorders reach their highest listening and/or spoken communication potential.

I took the challenge and will be posting my written description of the session in Part II of the “Say NO to Selection Tasks Challenge” blog post.

And I just had to donate to a charity near and dear to my heart!


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.

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.

Raising an Auditory-Verbal Therapist

Karen  MacIver-Lux

From an early age, I knew I was a privileged little girl.

My idea of privilege, however, had nothing to do with money, popularity, or good looks. For me, it was being able to hear with easy-to-hide hearing aids, and not having to wear eye-glasses like my best friend did.

That and being able to hear and speak English, which was downright difficult to learn with a bilateral severe to profound hearing loss with ’70’s hearing technology.

It took my mother, and a small village of trusted professionals to raise me to be the joyful listener and speaker that I am.

Once I grew up I became determined to “give back”, ultimately studying to become an audiologist and training to be an LSLS Certified Auditory-Verbal Therapist (LSLS Cert. AVTTM).

Over the years, I have adopted a number of practices that continue to help me in my endeavours to be the best AVT that I can be. The following tips are a few that I share with budding auditory-verbal therapists:

Adopt the 'Yes We Can' philosophyWhat made learning to speak difficult was not only the limitations of the ’70’s hearing technology, but also the many well-meaning professionals who categorically told my mother that I’d never learn to talk, never go to school, and would never get a job.

Luckily for me, if you want my mom to do something, just tell her she can’t do it, and she will do it just to prove you wrong.  Despite her determined “yes we can” philosophy, it was extremely disheartening to hear the negativity over and over again.  What did it accomplish other than to create days and nights of tears and anxiety?  Nothing.

During my years in practice I have observed that parents want and need to feel encouraged in order to see the value of consistent hearing technology use and weekly auditory-verbal therapy sessions. They are, after all, my primary clients.

“Clinical positivity” (reporting positive aspects of clinical findings and observations) is what breeds encouragement and plants the seeds of success.

Some examples of “clinical positivity” include:

  • explaining to the parents what their child with hearing loss CAN hear at time of diagnosis,
  • pointing out those occasions when their child showed positive outcomes in areas of audition, speech, language, cognition and communication,
  • being positive and when in doubt, use expressions like, “I don’t know, but let’s try!”

Learn to ListenYes, as a therapist I, too, need to learn to listen—not only to the children, but more importantly, their parents/caregivers.  When a parent/caregiver begins talking, I have learned to become quiet, lean in, wait (even when there is a pregnant pause), and most of all, maintain eye contact.

Therapy session

When parents speak out of frustration or anger, I try to listen and resist the urge to defend, explain and justify.  I focus on being an active and compassionate listener. Summarizing what I heard can be very helpful to them and to me.  I respond carefully to their concerns or issues once I am sure of their perspective. I try to put myself in the parents’ shoes and imagine what it must feel like raising a child while feeling uncertain of what the future holds.

I have been guilty of “listening” to parents while putting away toys, wiping the table, or writing notes in my chart.

Please don’t do this.  Parents look forward to having the opportunity to share their progress and their child with you, not the back of your head.

Keep your mentor closeI am fortunate to have a mentor to turn to for honest feedback, support, and professional guidance.

I don’t always like what I hear, but I’ve learned through experience to listen carefully to what he says, not to take criticism or constructive feedback personally, and when I disagree, to go ahead and try what he suggested because it usually ends up being the best advice.  He has earned my trust.

Find a mentor that you admire and trust—a good mentor who takes the time to listen to your stories of challenges and successes, a person who will support and encourage you in your growth as a career professional.

Don't Forget the Child’s Eye View (and Smell)

As a child I endured many years of therapy in a room with grey walls devoid of pictures, cabinets full of toys and treasures hiding behind locked doors, a tiny table and uncomfortable chairs that were either too small or big, and a room so big that the sound reverberated. I vowed that my therapy room (and sound booth) would be a cozy play-land with lots of bright colours, interesting toys, inviting books and pictures to look at.  I want the children and their families to see, hear, feel, love, and eagerly anticipate the meaningful auditory and spoken language opportunities I create for them.

Imagine that you are a child who cannot hear.  Stuff your ears with earplugs and get on your knees and crawl into your therapy room.  What does it look like?  What does it sound like? Is your therapy room warm and inviting?  Would you want to spend time in this room every week for three to five years?

I suggest refraining from drinking coffee, smoking, or eating strong-smelling foods before conducting a therapy session.

Pay attention to personal hygiene (which includes perfume).  As much as I hate to say it, there is nothing worse than sitting for an hour with a therapist who has a pungent smell.

Pay attention to the child’s personal space. I hated it when my therapists tapped me on the shoulder or hands, so I make a conscious effort not to do the same. If I need to be closer than 8 inches to the microphone of the child’s technology in order for the child to detect the entire speech spectrum, then I know I’m too close for the child’s comfort. The child will feel that you are breathing down their neck.

All of these are enough to turn a child who loves to please into a child who refuses to cooperate!

Remember the ‘Two Weeks and Then Move On’ Rule

I’ll never forget the day I started seeing a client who my mentor had been teaching.  I remember feeling so nervous!  How was I ever going to do therapy as well as my mentor did?

He made the sessions look so easy to do!  When it was my turn in the hot seat, I found myself stressing over which techniques and strategies to use and generally, making a big mess of things.

“Rome wasn’t built in a day” I reminded myself, deciding to focus on one technique—study it and practice it for two weeks.

If I mastered the use of the technique during therapy sessions, great!  If I didn’t, it was time for me to move on to another technique.  I would come back to the un-mastered technique some other time.  I even involved the parents in the process of helping me learn and use the techniques and strategies and we had fun learning together and laughing at our mistakes.

Unlike learning to acquire listening and spoken language skills, learning the tricks of the auditory-verbal trade is a career-long process— a process that is bound to be frustrating yet very rewarding at the same time.

To those of you who are budding AVTs, welcome to the world of auditory-verbal practice!  For those of us who are seasoned auditory-verbal therapists, we owe it to the children to find ways to raise the bar in auditory-verbal practice.


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.