sound practice in action
Posted by Karen MacIver-Lux on March 12, 2014 12:03 AM
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.
“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.
“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.
“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.
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.
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KAREN MACIVER LUX