sound practice in action
Posted by Stacey Lim on November 11, 2014 12:11 AM
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.
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.
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.
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.
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.
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 reviews the ten principles of LSLS Auditory-Verbal Therapy
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.
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.
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.
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.
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.
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