•www.agbell.org
•www.agbellacademy.org
•www.auditoryoptions.org
www.carolflexer.com
•www.hearingloss.org
•www.johntracyclinic.org
•www.listen-up.org
•www.ncbegin.org
•www.oraldeafed.org
•www.cochlear.com
•www.cochlearimplant.com
•www.cochlearimplants.com
•www.hear2learn.com
•www.hearingjourney.com
•www.kandersonaudconsulting.com
•www.nciohio.com
•www.voicefordeafkids.com
•www.nal.gov.au
www.avcclisten.com
www.cochlearimplantonline.com
About Me
- Lea Donovan Watson
- Listening and Spoken Language Specialist, Certified Auditory-Verbal Therapist, Speech-Language Pathologist, International consultant for LSLS training and children with hearing loss, husband-wife AVCC team, mother of three amazing individuals.
Monday, June 27, 2011
Friday, June 24, 2011
Auditory-Verbal Techniques and Hierarchies by Judith Simser
AUDITORY-VERBAL TECHNIQUES AND HIERARCHIES
Judith Simser
Consultant in Childhood Hearing Impairment
simser@magma.ca
In Auditory-Verbal practice there is an expectation that young children with hearing loss can use technologically assisted hearing to learn to listen, to process verbal language and to speak. The goal is that children with hearing loss can grow up in regular learning and living environments that enable them to become independent, participating, and contributing citizens in mainstream society. The A-V philosophy supports the basic human right that children with all degrees of hearing loss deserve an opportunity to develop the ability to listen and to use verbal communication in their daily lives. Adapted from Auditory-Verbal International, (1991)
Goldberg & Flexer and (2001) presented an outcome survey of children raised in Auditory-Verbal programmes. Ninety-three percent of the respondents were severely or profoundly deaf.
The questions in the survey revealed the following:
1) Do you consider yourself part of the hearing world, the deaf world, or both?
--- 76% consider themselves part of the hearing world
--- 21% consider themselves part of both the hearing and the deaf world
--- less than 1% was part of the deaf world
2) Nearly 90% had been fully mainstreamed in regular schools
3) 72% use the telephone
4) 94% went on to post-secondary education
Individualised auditory-verbal sessions
One of the principles of Auditory-Verbal Practice states that diagnostic therapy is individualised with parent participation1. By individualising therapy, therapists are able to adjust the program to account for differences in a child's and a parent’s personality, their learning styles, their interests, the degree of handicap and current functioning level of the child. In therapy sessions, a favourable learning environment is created for the parent and child with good acoustics, few distractions from others and a child in the presence of positive role models. Toys in a therapy program should replicate real life activities in a home environment. When the parent and child return to their home and community, they have ample opportunity in a natural setting to practice the skills and activities that they learned in therapy sessions. It is beneficial for the therapist to make an occasional home visit so that each family's home environment and living style is considered in therapy planning. Activities that replicate a specific family's routine activities in the home and community will foster the use of incidental language throughout their day. Children learn best by a parent/caregiver integrating targets that are unrecognised by the child, into to the child's daily life. Examples include:
• String up a clothesline between two chairs. Wash and hang out the doll's clothes.
• Buy fruit at a market. Return to the therapy session. Cut up the fruit and offer it to other children.
In the clinics in Taiwan there are situational therapy rooms: a bedroom, a living room and a kitchen to replicate those settings in the home. Parents are often nervous about children being in the kitchen. Parents learn that the kitchen has a wealth of listening, vocabulary and language learning opportunities when engaged in activities such as: making cookies, pudding, playdoh, toast with facial parts drawn with butter, cutting vegetables and sandwiches, making simple picture-drawn recipes. Many of these activities can be recreated in any therapy room!
Location of sessions
The auditory-verbal approach can be practised everywhere! Sessions can be held at the park, at the train station, at the local market or shopping centre or simply during a walk in the neighbourhood.
Why parents participate
It is through participation in therapy sessions that parents practice techniques and integrate targets into daily living. They obtain educational support, counselling, and guidance to enable them to become actively involved, thus developing a greater sense of confidence and control. Parents collaborate with the therapist in adapting play activities to their child's interests and abilities. They interpret the meaning of their child's communicative attempts. Parents serve as a communicating partner in responding to a variety of linguistic features such as answering questions and using pronouns. Parents help to model communication techniques such as: turn taking routines, postures to promote thinking and listening, pausing and responding. By participating, parents gain insight into the forthcoming stages of development of their child. As parents develop their skills in active and critical listening, they learn to see the constant interplay of targets. Any one event can incorporate targets in listening, speech, language, cognition and communication. Targets and specific examples are given to parents/caregivers and classroom teachers to co-ordinate efforts and to build upon listening basics. When parents learn how to integrate auditory-verbal techniques into everyday meaningful activities and experiences, their children have the best opportunity to develop a good listening and language outcome. Parents can become the professionals’ greatest allies. To ignore their contribution is to compromise a child’s future.
Therapists may discourage a parent's participation because often it is easier for a therapist, (as an authority figure) to maintain control of a child without a parent in the room. However, it is not the number of teacher contact hours that develops a child’s language! Or is it the number of hours sitting at a table doing "therapy". It is not the quantity or quality of toys! A foundation of language is developed through natural interactions about topics that are meaningful and interesting to a child. A parent's work is a child's play!
Most early language learners do not have sufficient language to access the set curriculum developed by boards of education. How can a child follow academic subjects when a child doesn’t have the language to request needs, explain feelings and observations, to communicate and to learn? An individualised program, suited to the parent and child’s needs, is created through ongoing assessment and teaching; as well as the teamwork of parents and therapist.
Parents are instructed in techniques to be the primary language facilitator for their child. Parent's active participation in therapy sessions can be reinforced by the therapist in the following ways:
• stating the goal to the parent before beginning an activity.
• modelling strategies clearly.
• beginning the activity then turning it over to the parent.
• providing encouraging feedback to parents.
• discussing how the parent would implement goals in other environments.
Parent progress
There are a variety of ways to assess and guide parents in their interactions with their child. Most methods involve interactional approaches such as in "Bromwich's Parent Behaviour Progression Form".2 Parent behaviours during different stages of their infant or child’s development are recorded as observed or reported during conversations. In Cole's book, she provides a checklist, "Caregivers: Communication-Promoting Behaviours." This lists desired observations during interactions between parent and child.3 These forms can provide a framework for further discussion between a therapist and parent.
Observe parent-child interaction
Frequently therapists will benefit from asking parents to bring some materials and activities from home. Parents may then play with their child while the therapist observes. Some parents may prefer that the therapist watch through a one-way mirror if available or sessions may be videotaped for discussion later. To build on the parents’ strengths, it is important that the therapist emphasises the effective content and techniques that the parents use. Then by modelling, the therapist can help the parents grow in skills and confidence. Many an anxious parent may succumb to the trap of continually testing their child. This often leads to parent-child conflict. It is suggested to leave the assessment to the therapist so parents can more readily follow their child's lead and develop a mutual trust in play.
COMPONENTS OF AUDITORY-VERBAL THERAPY
With the beginning listener emphasis should be on providing the individual with plenty of listening opportunities with few demands for speech production. With severe to profound congenital deafness, very young children (from one to two years) are best suited to receiving a cochlear implant, as they are quick to learn through hearing. There is good plasticity of the brain during these critical language learning years. It is common for toddlers and children to develop natural gestures during the first two years of life. Most children with hearing loss will not have developed another mode of communication if implanted early. Most of them live at home with their parents/caregivers in a setting conducive to developing natural language and thus these children are in an ideal position to benefit from Auditory-Verbal techniques. For the older, very visual learner, parents will need to help their child transition gradually from a visual to an auditory mode. By following the beginning stages in developing of listening skills in contrived and natural settings and by initially preceding and then confirming auditory input with situational cues, a child can begin to develop comprehension through listening. By building upon weekly listening, speech and language targets and by expanding on language learned through hearing, a child’s confidence in listening will increase.
Individualised diagnostic sessions are routinely held once weekly for one to one and a half hours. The following outline describes some essential components of a therapy session and factors to be considered in planning:
SEGMENTS OF SESSIONS FACTORS TO CONSIDER
All components are to be integrated into daily natural, useful and meaningful routines & play activities.
Hearing aid or CI function check Child and parent participation
Development of listening skills Aims and materials
Speech perception and production Parent-child-therapist interaction
Language development Integration of segments
Cognitive development Unplanned learning and flexibility
Communication competence Pace and motivation
Parent discussion and setting targets Listening to the child and parent
AUDITORY-VERBAL TECHNIQUES
The following are some of the techniques used in Auditory-Verbal education to enhance a child’s listening, speech and language skills.
1. THE HAND CUE
The HAND CUE is one of the most useful yet frequently misunderstood techniques used in auditory-verbal practice. Some individuals incorrectly equate the hand cue as the main feature of Auditory-Verbal education. It is only one of many A-V techniques used to develop a child’s listening and spoken language. Questions arise: “What is the hand cue and why do we use it?” “Do we block the acoustic signal?” “Is it used in school?”
“WHAT IS A HAND CUE?”
It is a cue to listen! It is a cue to alert children to the fact that someone is talking to them and that they need to attend to listen. The speaker emphasises listening by shielding his or her mouth from the child’s view. Care must be used not to cup the hand over the mouth, preventing acoustic information from fully reaching the child. A flat, slanted hand held slightly above the mouth encourages a child to listen rather than seek visual cues. When the caregiver or therapist places their hand in front of a child’s mouth, it is a child’s prompt to respond, either through imitation or spontaneous speech.
A hand cue is especially useful when talking to a visually oriented child with hearing loss who is searching for visual cues.
“WHY IS A HAND CUE USED AND WHEN?”
A hand cue is unnecessary with young infants and babies or for children who are keen and effective listeners, as they tend not to search for visual cues and usually focus on toys and activities around them. However in most Auditory-Verbal programmes many children with hearing loss entering the clinics have not had the opportunity to learn to listen. This is usually due to late and/or inappropriate amplification with hearing aids or teaching methods that have not emphasised auditory learning. Naturally, these children learn to substitute their sense of vision for their lack of listening development. Unless their sense of hearing is emphasised, these children continue to function as deaf. American Doreen Pollack, a pioneer in the auditory-verbal approach, made the following observations:
“I learned that one could not simply hang a hearing aid on children and expect them to develop hearing perceptions normally. Instead the children continued to act as if they were deaf. Sound was meaningless. When the children were encouraged to use lip-reading or signing, they continued to be visual learners and ignored sound.
I came to realise that one did not have to teach deaf children to look but instead one had to teach them to listen. A hearing aid gave more hearing, but listening had to be learned. I had to make sound an important and meaningful part of everything the children were experiencing.”
If a child has a profound hearing impairment and has insufficient aided hearing to access the speech range to develop spoken language through hearing, his/her parents may chose cochlear implantation for their child. Once the cochlear implant is programmed, this child will be a beginning auditory learner and with effective auditory-verbal techniques will gradually transition from using only vision to developing his/her newfound hearing potential by learning to listen.
“WHO USES THE HAND CUE?”
Audiologists, speech language pathologists, or educators of the deaf, any professional who has developed the techniques of the Auditory-Verbal approach, may introduce the hand cue to the child’s primary caregivers when deemed beneficial. It should not be used by school classroom teachers and friends but mainly by parents or other key caregivers in a child’s environment. When acoustics are less favourable then a child with hearing impairment he/she will need to use visual cues and body language to supplement hearing, as does a typically hearing individual. Many speech/language pathologists have found the hand cue useful in highlighting listening in certain cases of children with normal hearing.
“CAN TECHNIQUES OTHER THAN THE HAND CUE BE USED TO EMPHASIZE HEARING?”
Yes! The primary caregiver should sit beside the child, close to the microphone of the better ear with the hearing technology. The closer they are to the child’s ear the softer the voice to ensure the opportunity to hear the less salient speech sounds. Vowels are louder than consonants and often mask a child’s hearing of the softer consonants. This is often evident in a child’s speech when consonants are deleted or substituted. No hand cue is necessary with preferential seating unless the child is actively searching for visual cues.
The therapist or teacher can suggest that the older child turn away to emphasise listening. This helps the child attend to the listening task and to concentrate on what is heard.
“WHEN DO YOU STOP USING A HAND CUE?”
When a child has a natural listening interaction, a hand cue is not necessary. However it is useful to continue using auditory techniques to gain a higher level of auditory learning such as listening in noise, talking on the telephone and overhearing conversations. Many an adult with hearing loss seeks further therapy to practise and enhance their auditory skills. The greater the skills in listening the greater the ability to monitor one’s voice and speech quality. This explains why effective auditory-verbal listeners usually have natural sounding speech.
2. ACOUSTIC HIGHLIGHTING
The earliest form of acoustic highlighting used is called “Motherese” or “Parentese.” It is speech used by parents/caregivers in talking with young children to make speech more audible to help them in learning language. Research by Dr. Patricia Kuhl indicates that parentese is universal and plays a vital role in helping infants analyse speech. The use of early highlighting is an auditory technique that is extended in communicating with the beginning hearing aid or cochlear implant user to increase the audibility of language. As a child learns to listen, the aim is to progress towards a more normal, less highlighted mode of communication.
Examples of acoustic highlighting are as follows:
MORE AUDIBLE progressing to LESS HIGHLIGHTING
(for a beginning child) (for a child who is listening well)
No background noise Increased background noise
6” from hearing aid or Increased distance from
C.I. hearing aid or C.I.
Simpler language with Complex sentences
shorter phrases
Greater acoustic contrast Less varied acoustic contrast
(vowel variation, rhythm and syllable (minimal pairs, similar rhythm)
contrast)
Emphasis on key words No emphasis on key words
Emphasis on words not accentuated, No emphasis
(prepositions, articles, verb tenses,
pronouns)
Word position in sentence:
End of sentence Middle Beginning
Closed set Open set
Slightly slower rate Normal rate
Increased pitch variation Normal rhythm
and rhythm
(sing what you say)
Clearer enunciation Less clear and/or unfamiliar
(use of “clear” speech) voice
Increased repetition No repetition
© Judith I. Simser
However, having reached the goal of less highlighting, it must be remembered that there are many noisy acoustic environments where acoustic highlighting may continue to be necessary just as it is with those who have normal hearing.
3. AUDITORY FEEDBACK
When children imitate or use spontaneous speech, they match their voice production with the speech patterns of others thus monitoring their own speech production. Besides this direct auditory feedback, children receive indirect feedback from the listener’s reactions to their vocalisations and speech, which further reinforces the quality of their production. In auditory directions, asking children to imitate what they heard, discourages guessing as it serves to verify what the children heard before attempting the task.
4. PAUSING AND WAITING
Children with hearing impairment may take longer to process auditory information, so the technique of pausing and waiting with anticipation encourages a child to listen and follow through with a task rather than waiting for the speaker to repeat.
When a child has developed some spoken language through hearing and is not attending well to auditory input he/she may respond to auditory input with “What?” or may sit there with a blank expression on his/her face. To emphasise listening, pause and then ask, “What did you hear?” This technique helps the child how develop clarification skills. You may discover that they have heard you and will respond appropriately or they will clarify by telling how much of the input they grasped.
5. NATURAL SEQUENTIAL DEVELOPMENT
In order to ensure success each child needs to progress through a hierarchy of listening, speech, language, cognitive and communication skills, much like a typical child. The Auditory-Verbal therapist develops targets based on a hierarchical model, (from most audible to least audible) and on normal stages of development in these areas. Input is provided primarily through audition. Only too often a child and his family experience failure because targets are too difficult and do not follow a natural sequential order. In developing speech through hearing, a developmental program is used. Initially, variations in vowel content and suprasegmentals offer good acoustic contrast aiding in speech perception. (See Appendix A-Suggestions for Highlighting Beginning Vocabulary). Speech babble is used to develop speech perception. As speech perception improves, there is a reciprocal benefit in speech production, Ling, D. (1987). Just as we repeat syllables in learning new words or a new language, so do we encourage the use of syllabic babble to heighten the auditory perception and production of speech sounds. Once a child produces targeted syllables, these phonemes must be reinforced in spoken language. Language targets follow a hierarchy of normal development but also of available acoustic cues.
In developing a listening function, there is a constant interplay of targets in listening, speech, language, communication and cognition in all interactions throughout a child’s day, with any variety of targets incorporated into any one event. Weekly targets are given to parents/caregivers and classroom teachers to co-ordinate efforts and to build upon listening basics. When parents integrate Auditory-Verbal techniques and targets into everyday, meaningful activities and experiences then their children have the best opportunity to develop good listening and language outcomes. Only once children have developed language can they then access school curricula.
LEARNING TO LISTEN
Guidance in creating a listening, learning environment is pertinent to the beginning stages, regardless of age.
Suggestions include some of the following:
• Enhance the acoustic environment by being close to the microphone of a child’s cochlear implant or the hearing aid of the better ear. Encourage listening by sitting beside a child, (not across), and focusing on objects in front of parent and child.
• Be aware of and minimise background noises especially the noise of an air conditioner, television, fridge or radio.
• This student is a BEGINNER. Assist a child by making speech more audible using parentese; that is, spoken language that is rich in suprasegmental qualities, repetitive in nature, initially focusing on low and mid-frequency vowel content, and in the context of short, meaningful two-to-three-word phrases.
• Throughout the day cue a child to “listen” while pointing to your ear to alert a child to attend to auditory input and meaningful environmental sounds. Observe a child’s listening and responding behaviours such as cessation of movement, eye contact to an object or person, imitation of a sound or a response indicating listening through body posture.
• Follow a child’s interest level in age and stage appropriate activities and experiences with specific targets integrated.
• Reinforce the expectation that with Auditory-Verbal techniques a child will learn to listen
THE ONGOING ASSESSMENT FORM
The following form presents hierarchies in the areas of audition, language, speech, cognition and communication although it is by no means complete. It serves as a quick evaluation form, as a diagnostic tool to help in setting ongoing targets and as a means to discuss progress with parents.
SIMSER AUDITORY-VERBAL ONGOING ASSESSMENT FORM
© Judith I. Simser
Name: DOB: Date started A.V.:
Hearing loss: Hearing aid model or implant:
Key: Beginning ┴ Inconsistent + Consistent Expressive Use (Cross out check)
AUDITION
Ling 6 Sound Test: detection & identification m__ u__ a__ i__ sh__ s__ silence__
distance (12 cm. 50 cm. 1 m. 2 m.): m___ u___ a___ i___ sh___ s___
words in phrases: 1. vowels + syllables differ ___ 3. rhyming words ___
2. same consonant, vowels differ ___ 4. final consonants only differ ___
auditory memory: 1 __ 2 __ 3 __ 4 __ 5 __ items
identification of consonants by: manner ___ songs & rhymes ___
voicing___ auditory attention to extended
place___ conversations & stories ___
selection by description: closed set - stage 1. sound-word repeated ___ 2. identify by key words ___
3. include objects with similar characteristics ___ 4. begin levels 1 & 2 in open set
open set - stage 1. sound-word repeated ___ 2. identify by key words ___
3. complex description ___ 4. identify by questioning___
taped instructions and stories____ listening in noise ___ group conversations ___
LANGUAGE
dates:
Vocabulary (1st year only): comprehension ___ wds ___ wds ___ wds ___ wds
spontaneous use ___ wds ___ wds ___ wds ___ wds
---------------------------------------------------------------------------------------------------------------------
nouns: sound-word ___ subject nouns ___ object nouns ___ parts of objects ___
by description___ plural nouns, irregular ___ regular___
verbs: directives ___ present progressive ___ future ___ past tense ___ conditional ___
pronouns: mine ___ I ___ you ___ he ___/or she ___ they ___ him ___
her ___ them ___ his ___ hers ___ theirs ____ we ___ us___
it ___ our ___ yours ___ myself ___ who/whom ___
prepositions: up ___ down ___ in or on ___ under ___ behind ___ beside ___
in front ___ in/on ___ cont. with concept list ___
adjectives and adverbs: beginning list ___ concept list ___
negatives: no ___ not ___ don't ___ isn't ___ can’t ___ didn’t ___ wasn’t ___
conjunctions: and ___ not the ___ either-or ___ only ___ everything but ___
neither-nor ___ because ___ so ___ if ___ before ___ after ___
articles: a ___ the ___
questions: What's that? ___ What's he doing? ___ What's it for? ___
What happened? ___ How many? ___ What colour? ___ Where? ___
What's missing? ___ Who is it? ___ Why? ___ When? ___ How? ___
auxiliary questions: do ___ are ___ is ___ can ___ does ___
examples of spoken language (bracket missing parts of speech) i.e., Daddy(‘s) car no (won’t) go.
date _________________________________________________________________________
date _________________________________________________________________________
SPEECH
voice quality (low 1- 5): ___ speech intelligibility (1-5): in context ___ out of context ___
suprasegmentals: duration: long ___ short ___ varied ___
intensity: loud ___ soft ___ varied ___
frequency: high___ low ___ varied ___
vowels: u___ a___ o___ æ ___ - i ___ ʌ ___ ɑ __ ɛ ___ - ʋ ___ e ___ ɝ ___ ɔ ___ ɪ ___
vowels alternated: u-a ___ a-u ___ - i-a ___ e-i ___
diphthongs: (ow) aʋ ___ (eye) aɪ ___ (aye) eɪ ___ (oy) ɔɪ ___
consonants: level 1 - p ___ b ___ m ___ h ___ w ___
level 2 - t ___ d ___ n ___ f ___ v ___ (sh) ʃ ___ ʒ ___ r ___ (y) ј ___
level 3 - k ___ g ___ l ___ (ng) ŋ ___ s ___ z ___ (th) θ ___ (th) ð ___
unreleased plosives _________________________
affricates: (ch) ʧ ___
(dg) ʤ ___ Adapted from Ling, D. (2002). Speech and the hearing impaired child:
Theory and Practice. 2nd Edition. Washington, DC:
Alexander Graham Bell Association for the Deaf.
blends: word initial – sequential ____________ coformulated _____________ complex blends ______
word final – continuant-continuant ___ continuant-stop ___ stop-continuant___ stop-stop ___
COGNITION
sorting: identical objects ___ categories ___ by function, shape, colour, number, texture, content
go togethers: real objects ___ cards or puzzles___ colours: red ___ blue ___ green ___ yellow ___
rote counting: 1-10 ___ number concepts: 1-3 ___ 4-6 ___ 7-10 ___ 11-20 ___ no. after___ no. before___
no. in-between ___ count by twos, threes ___ addition by one ___ by twos ___ subtraction by one___ create equal sets___ number stories ___
shapes: circle ___ square ___ star ___ triangle ___ rectangle ___
textures: soft ___ rough ___ continue concept list ___
comparisons: same___ different ___ doesn't belong ___ how alike ___ categorise and give reasons why ___
sequencing: shapes ___ colours ___ patterns ___ 2-4 pt. story ___ events ___ tell story __ multiple endings__
identity of an object ___ opposites ___ analogies ___ inferences ___ synonyms ___
double meanings ___ simple jokes ___ riddles ___ idioms ___
COMMUNICATION
has appropriate eye contact ___
practises turn taking ___ uses courtesy language: e.g., bye, I'm sorry, excuse me ___
initiates interactions ___ uses questioning ___
initiates conversational topics ___
repair strategies: asks for repetition ___ uses appropriate topic transitions ___
verifies partial information ___ shares conversational control ___
asks for clarification ___ provides clarification ___
maintains topic: 1 turn ___ 2 turns ___ 3 turns ___ extends conversation ___
NOTES:
© Judith I. Simser
AUDITORY MEMORY DEVELOPMENT
The items underlined indicate examples of the items a child needs to identify to understand the directions or information.
*Develop ability to follow a one-item memory task:
1. containing repetition of sound-word association in phrases, e.g.” The ball goes bounce, bounce, bounce.”
2. in single repetition of a sound-word association, e.g.” Where’s the cat that goes meow?”
3. in single objects representing nouns, verbs, adjectives and common phrases with varied suprasegmentals and vowel content, e.g. “Pick the flower” vs. “Wash, wash, wash your hands” vs. “Mmm, that’s good.”
4. in single objects varying in vowel content and syllables, e.g. “Where’s the spoon?” vs. apple vs. ice cream cone.
5. with word presented at end of sentence, e.g. “Please get the bananas.”
6. with word presented in middle or at beginning of sentence to prepare for two item memory, e.g. “Please put the bananas on the table,” while the speaker is pointing to the table.
Develop the ability to respond to two-item memory phrases:
1. two nouns, e.g. “Get your shoes and your hat.”
2. noun and verb, e.g. “The baby is sleeping.”
3. verb and object, e.g. “Wash the car.”
4. two verbs, e.g. “Jump and sit down.”
5. adjective and noun, e.g. “Go get your blue shirt.”
6. number and noun, e.g. “I want three candies.”
Develop the ability to process a three-item memory task:
1. three nouns, e.g. “Don’t forget your running shoes, your coat and your books.”
2. two nouns and a verb, e.g. “The boy and the dog are running.”
3. noun, and two verbs, e.g. “Daddy is washing and then having supper.”
4. noun, preposition and object, e.g. “Put your umbrella under your chair.”
5. two nouns and a conjunction, e.g., “You can have either an apple or a banana.”
6. two adjectives and a noun, e.g., “Make a big, brown tail.”
7. Pronoun, verb and object, e.g., “She is cutting the bread.”
Develop auditory memory tasks of four-to-five items:
1. four nouns, e.g. “When we’re shopping, we need bread, ice cream, fruit, and crackers.”
2. nouns, preposition and object, e.g. “Put your shovel and your bike behind the house.”
3. noun, conjunction, preposition and object, e.g., “Get some popcorn or some chips and put them beside the TV.”
4. two noun-verb phrases, e.g., “The boy is swinging and the girls are sliding.”
5. add a descriptive phrase, e.g., “See the lady wearing the blue dress in front of the store?”
6. add a time factor, e.g., “After you do your homework for one hour, you can watch TV.” “Before you wash your hands , you need to clean your black shoes.”
The above memory tasks can be practised in real life but also in contrived play by using toys for role-playing. Try to integrate memory tasks into daily living rather than making them task oriented.
SELECTION BY DESCRIPTION
A child begins to listen to longer information by identifying known vocabulary by its description in a closed set (where a choice of objects is visible to the child). Begin after the child has about a two-item memory.
1. where a known word or object representing a sound-word is used repeatedly, e.g. “It flies, up, up, up in the sky, it goes ah….ah, you ride in it.” “What is it?” Use a choice of four objects of different categories and all known vocabulary. For example, a shoe, a ball, a car and a dog.
2. identify an object by attending to a single repetition of familiar key words in the description, e.g., “It has four legs, it swims in the water, it hops and it is green. What is it? All characteristics in the choice of objects should vary.
3. include some objects that have a few similar characteristics, e.g., a bird and an airplane both fly; a fish and a frog both swim in the water.
4. *begin open set descriptions beginning with steps 1 and 2 above.
EXAMPLES OF BEGINNING LANGUAGE TARGETS DEVELOPED CONCURRENTLY WITH LISTENING, SPEECH, COGNITION & COMMUNICATION
- pronoun development, (“I, you, your, mine”)
- comprehension and use of prepositions (“in” or “on”) vs. (“under” or “behind”) in games, in cooking and eating activities, in creating crafts
Once a child develops phrases, record examples of child’s language and bracket the missing words so that these can be targeted and reinforced in future play activities and routines. For example, “I walk(ed) (to) the store (with) Mummy.” “Daddy(’s) car no (won’t) go!”
SPEECH DEVELOPMENT
In developing speech through hearing, a developmental rather than remedial program is used. Speech babble is used to develop speech perception. As speech perception improves there is a reciprocal benefit in speech production, Ling, D. (1997). Just as we repeat syllables in learning new words or a new language, so do we encourage the use of syllabic babble to heighten the auditory perception and production of speech sounds. Segments of therapy will involve practise in identifying early emerging phonemes such as vowels [a], [u], [o] and [i] and consonants [b], [m], (sh) and whispered [p] and [h]. Initially do not combine [u] with [m] as these will sound too similar to the beginning listener. The young child can practise phoneme perception by playing with objects with the above phonemes as associated sounds, (see Appendix A) and the older child can listen to identify them by their phonetic equivalents. When phonemes are identified, encourage production in syllabic babble and once achieved, phonemes should be transferred into phonology. Suggestions to develop intelligible speech include the following:
• listen carefully to a child’s speech to analyse speech errors rather than lip-reading him/her.
• in all speech techniques attempt to elicit a phoneme through hearing first. If a visual or tactile cue is used, once the child produces the sound, have him/her say it repeatedly using hearing only for auditory feedback to occur.
• when phonemes are missing, distorted or substituted, soften voice, get close to the implant or hearing aids and acoustically highlight the defective phoneme in syllabic babble. Once well produced in syllabic babble, transfer to phonology.
• continue to improve the suprasegmental qualities of speech. To aid in intelligibility emphasise rhythm in word groupings to create short phrases. For example, “My sister…went to school…on the school bus.”
• as a child progresses, use less acoustic highlighting with goal of more normal speech reception and production.
APPENDIX A
SUGGESTIONS FOR HIGHLIGHTING BEGINNING VOCABULARY
Vehicles
boat - p-p-p (unvoiced) car - b-r-r-r (truck)
airplane - a-a-a train - oo-oo-oo bus - bu-bu-bu
Animal sounds
cow - moo dog - bow-wow horse - neigh
cat - meow lamb - ba-a-a fish - swish
pig - oink frog - hop-hop-hop chicken - cluck
bird - chirp duck - quack-quack monkey - ee-ee-ee
owl - hhoo lion - rroar-rroar bear - grr-grr
Action Words Adjectives Nouns
push-push it down that’s hot the watch goes tic-toc
mmm- smell the flower it’s all gone hi baby
wake-up it’s dirty I’m Mummy, Daddy
pop-pop the bubbles it’s soft that’s my shoe
sh-h go to sleep it’s broken slide-up, up, up wee-e
sit down it’s wet that’s my eye, nose, mouth
wash-wash your hands it’s sticky look at the fish
have a drink the clown says ha ha ha
blow-blow the feather Santa says ho ho ho
walk-walk-walk Pronouns
bounce-bounce the ball
go-up-up-up (stairs and lift me up) that’s mine
it goes round and round give it to me
cut-cut....cut the banana
brush your hair, teeth
jump, jump, jump
Common Phrases
bye-bye no-no-no, don’t touch stop it
look at that uh-oh it fell down brr that’s cold
it’s too heavy that’s pretty help me
ow, it’s sore m-m-m that’s good I want more
I want a ______ what a mess pick it up
that’s funny wait a minute
© Judith I. Simser
REFERENCES
Auditory-Verbal International. (1991). Guiding principles. Auricle. Fall Vol.3. Alexandria, VI.
Bromwich, R. (1981). Working with parents and infants. Baltimore, MA: University Park Press.
Cole, E. (1992). Listening and talking: A guide to promoting spoken language in young hearing impaired children. Washington, DC: Alexander Graham Bell Association for the Deaf.
Estabrooks, W., Editor, (2001). 50 FAQ About AVT, Toronto, Ont.: Learning to Listen Foundation
Estabrooks, W., Editor, (1994). Auditory-verbal therapy for parents and professionals, Washington, DC: Alexander Graham Bell Association for the Deaf.
Flexer, C. (1999), Facilitating hearing and listening in children. (2nd Ed.). San Diego, CA: Singular Publishing Group
Goldberg, D.M &. Flexer, C. (1993) Outcome survey of auditory-verbal graduates: Study of clinical efficacy. Journal of the American Academy of Audiology, 4, 189-200.
Ling, D. (2002). Speech and the hearing impaired child: Theory and Practice. 2nd Edition. Washington, DC: Alexander Graham Bell Association for the Deaf.
Ling, D. (1989). Foundations of spoken language for hearing-impaired children. Washington, DC: Alexander Graham Bell Association for the Deaf.
Ling, D., & Ling, A.H. (1978). Aural habilitation: The foundations of verbal learning. Washington, DC: Alexander Graham Bell Association for the Deaf.
Luterman, D. (1999). The young deaf child. Baltimore, Maryland. York Press, Inc.
Pollack, D., Goldberg, D., & Caleffe-Schenck, N. (1997). Educational audiology for the limited-hearing infant. Springfield, IL: Charles C. Thomas (3rd Edition).
Simser, Judith, (1999). Parents, the essential partners in the habilitation of children with hearing impairment, in the Australian Journal of Education of the Deaf, Vol. 5, Adelaide, South Australia.
Simser, J.I. (1993). Auditory-verbal intervention: Infants and toddlers. The Volta Review, 95, (217-229).
Simser, J., & Steacie, P. (1993). A hospital clinic early intervention program. In A. Phillips & E. Cole (Eds.), Beginning with babies: A sharing of professional experience. Washington, DC: Alexander Graham Bell Association for the Deaf.
Stokes, J. (Ed.) (1999) Hearing impaired infants: Support in the first eighteen months. Washington, D.C. Alexander Graham Bell Association for the Deaf.
Talbot, Pam. (2002). Topics in Auditory-Verbal Therapy, Virginia, Auditory-Verbal International.
Judith Simser
Consultant in Childhood Hearing Impairment
simser@magma.ca
In Auditory-Verbal practice there is an expectation that young children with hearing loss can use technologically assisted hearing to learn to listen, to process verbal language and to speak. The goal is that children with hearing loss can grow up in regular learning and living environments that enable them to become independent, participating, and contributing citizens in mainstream society. The A-V philosophy supports the basic human right that children with all degrees of hearing loss deserve an opportunity to develop the ability to listen and to use verbal communication in their daily lives. Adapted from Auditory-Verbal International, (1991)
Goldberg & Flexer and (2001) presented an outcome survey of children raised in Auditory-Verbal programmes. Ninety-three percent of the respondents were severely or profoundly deaf.
The questions in the survey revealed the following:
1) Do you consider yourself part of the hearing world, the deaf world, or both?
--- 76% consider themselves part of the hearing world
--- 21% consider themselves part of both the hearing and the deaf world
--- less than 1% was part of the deaf world
2) Nearly 90% had been fully mainstreamed in regular schools
3) 72% use the telephone
4) 94% went on to post-secondary education
Individualised auditory-verbal sessions
One of the principles of Auditory-Verbal Practice states that diagnostic therapy is individualised with parent participation1. By individualising therapy, therapists are able to adjust the program to account for differences in a child's and a parent’s personality, their learning styles, their interests, the degree of handicap and current functioning level of the child. In therapy sessions, a favourable learning environment is created for the parent and child with good acoustics, few distractions from others and a child in the presence of positive role models. Toys in a therapy program should replicate real life activities in a home environment. When the parent and child return to their home and community, they have ample opportunity in a natural setting to practice the skills and activities that they learned in therapy sessions. It is beneficial for the therapist to make an occasional home visit so that each family's home environment and living style is considered in therapy planning. Activities that replicate a specific family's routine activities in the home and community will foster the use of incidental language throughout their day. Children learn best by a parent/caregiver integrating targets that are unrecognised by the child, into to the child's daily life. Examples include:
• String up a clothesline between two chairs. Wash and hang out the doll's clothes.
• Buy fruit at a market. Return to the therapy session. Cut up the fruit and offer it to other children.
In the clinics in Taiwan there are situational therapy rooms: a bedroom, a living room and a kitchen to replicate those settings in the home. Parents are often nervous about children being in the kitchen. Parents learn that the kitchen has a wealth of listening, vocabulary and language learning opportunities when engaged in activities such as: making cookies, pudding, playdoh, toast with facial parts drawn with butter, cutting vegetables and sandwiches, making simple picture-drawn recipes. Many of these activities can be recreated in any therapy room!
Location of sessions
The auditory-verbal approach can be practised everywhere! Sessions can be held at the park, at the train station, at the local market or shopping centre or simply during a walk in the neighbourhood.
Why parents participate
It is through participation in therapy sessions that parents practice techniques and integrate targets into daily living. They obtain educational support, counselling, and guidance to enable them to become actively involved, thus developing a greater sense of confidence and control. Parents collaborate with the therapist in adapting play activities to their child's interests and abilities. They interpret the meaning of their child's communicative attempts. Parents serve as a communicating partner in responding to a variety of linguistic features such as answering questions and using pronouns. Parents help to model communication techniques such as: turn taking routines, postures to promote thinking and listening, pausing and responding. By participating, parents gain insight into the forthcoming stages of development of their child. As parents develop their skills in active and critical listening, they learn to see the constant interplay of targets. Any one event can incorporate targets in listening, speech, language, cognition and communication. Targets and specific examples are given to parents/caregivers and classroom teachers to co-ordinate efforts and to build upon listening basics. When parents learn how to integrate auditory-verbal techniques into everyday meaningful activities and experiences, their children have the best opportunity to develop a good listening and language outcome. Parents can become the professionals’ greatest allies. To ignore their contribution is to compromise a child’s future.
Therapists may discourage a parent's participation because often it is easier for a therapist, (as an authority figure) to maintain control of a child without a parent in the room. However, it is not the number of teacher contact hours that develops a child’s language! Or is it the number of hours sitting at a table doing "therapy". It is not the quantity or quality of toys! A foundation of language is developed through natural interactions about topics that are meaningful and interesting to a child. A parent's work is a child's play!
Most early language learners do not have sufficient language to access the set curriculum developed by boards of education. How can a child follow academic subjects when a child doesn’t have the language to request needs, explain feelings and observations, to communicate and to learn? An individualised program, suited to the parent and child’s needs, is created through ongoing assessment and teaching; as well as the teamwork of parents and therapist.
Parents are instructed in techniques to be the primary language facilitator for their child. Parent's active participation in therapy sessions can be reinforced by the therapist in the following ways:
• stating the goal to the parent before beginning an activity.
• modelling strategies clearly.
• beginning the activity then turning it over to the parent.
• providing encouraging feedback to parents.
• discussing how the parent would implement goals in other environments.
Parent progress
There are a variety of ways to assess and guide parents in their interactions with their child. Most methods involve interactional approaches such as in "Bromwich's Parent Behaviour Progression Form".2 Parent behaviours during different stages of their infant or child’s development are recorded as observed or reported during conversations. In Cole's book, she provides a checklist, "Caregivers: Communication-Promoting Behaviours." This lists desired observations during interactions between parent and child.3 These forms can provide a framework for further discussion between a therapist and parent.
Observe parent-child interaction
Frequently therapists will benefit from asking parents to bring some materials and activities from home. Parents may then play with their child while the therapist observes. Some parents may prefer that the therapist watch through a one-way mirror if available or sessions may be videotaped for discussion later. To build on the parents’ strengths, it is important that the therapist emphasises the effective content and techniques that the parents use. Then by modelling, the therapist can help the parents grow in skills and confidence. Many an anxious parent may succumb to the trap of continually testing their child. This often leads to parent-child conflict. It is suggested to leave the assessment to the therapist so parents can more readily follow their child's lead and develop a mutual trust in play.
COMPONENTS OF AUDITORY-VERBAL THERAPY
With the beginning listener emphasis should be on providing the individual with plenty of listening opportunities with few demands for speech production. With severe to profound congenital deafness, very young children (from one to two years) are best suited to receiving a cochlear implant, as they are quick to learn through hearing. There is good plasticity of the brain during these critical language learning years. It is common for toddlers and children to develop natural gestures during the first two years of life. Most children with hearing loss will not have developed another mode of communication if implanted early. Most of them live at home with their parents/caregivers in a setting conducive to developing natural language and thus these children are in an ideal position to benefit from Auditory-Verbal techniques. For the older, very visual learner, parents will need to help their child transition gradually from a visual to an auditory mode. By following the beginning stages in developing of listening skills in contrived and natural settings and by initially preceding and then confirming auditory input with situational cues, a child can begin to develop comprehension through listening. By building upon weekly listening, speech and language targets and by expanding on language learned through hearing, a child’s confidence in listening will increase.
Individualised diagnostic sessions are routinely held once weekly for one to one and a half hours. The following outline describes some essential components of a therapy session and factors to be considered in planning:
SEGMENTS OF SESSIONS FACTORS TO CONSIDER
All components are to be integrated into daily natural, useful and meaningful routines & play activities.
Hearing aid or CI function check Child and parent participation
Development of listening skills Aims and materials
Speech perception and production Parent-child-therapist interaction
Language development Integration of segments
Cognitive development Unplanned learning and flexibility
Communication competence Pace and motivation
Parent discussion and setting targets Listening to the child and parent
AUDITORY-VERBAL TECHNIQUES
The following are some of the techniques used in Auditory-Verbal education to enhance a child’s listening, speech and language skills.
1. THE HAND CUE
The HAND CUE is one of the most useful yet frequently misunderstood techniques used in auditory-verbal practice. Some individuals incorrectly equate the hand cue as the main feature of Auditory-Verbal education. It is only one of many A-V techniques used to develop a child’s listening and spoken language. Questions arise: “What is the hand cue and why do we use it?” “Do we block the acoustic signal?” “Is it used in school?”
“WHAT IS A HAND CUE?”
It is a cue to listen! It is a cue to alert children to the fact that someone is talking to them and that they need to attend to listen. The speaker emphasises listening by shielding his or her mouth from the child’s view. Care must be used not to cup the hand over the mouth, preventing acoustic information from fully reaching the child. A flat, slanted hand held slightly above the mouth encourages a child to listen rather than seek visual cues. When the caregiver or therapist places their hand in front of a child’s mouth, it is a child’s prompt to respond, either through imitation or spontaneous speech.
A hand cue is especially useful when talking to a visually oriented child with hearing loss who is searching for visual cues.
“WHY IS A HAND CUE USED AND WHEN?”
A hand cue is unnecessary with young infants and babies or for children who are keen and effective listeners, as they tend not to search for visual cues and usually focus on toys and activities around them. However in most Auditory-Verbal programmes many children with hearing loss entering the clinics have not had the opportunity to learn to listen. This is usually due to late and/or inappropriate amplification with hearing aids or teaching methods that have not emphasised auditory learning. Naturally, these children learn to substitute their sense of vision for their lack of listening development. Unless their sense of hearing is emphasised, these children continue to function as deaf. American Doreen Pollack, a pioneer in the auditory-verbal approach, made the following observations:
“I learned that one could not simply hang a hearing aid on children and expect them to develop hearing perceptions normally. Instead the children continued to act as if they were deaf. Sound was meaningless. When the children were encouraged to use lip-reading or signing, they continued to be visual learners and ignored sound.
I came to realise that one did not have to teach deaf children to look but instead one had to teach them to listen. A hearing aid gave more hearing, but listening had to be learned. I had to make sound an important and meaningful part of everything the children were experiencing.”
If a child has a profound hearing impairment and has insufficient aided hearing to access the speech range to develop spoken language through hearing, his/her parents may chose cochlear implantation for their child. Once the cochlear implant is programmed, this child will be a beginning auditory learner and with effective auditory-verbal techniques will gradually transition from using only vision to developing his/her newfound hearing potential by learning to listen.
“WHO USES THE HAND CUE?”
Audiologists, speech language pathologists, or educators of the deaf, any professional who has developed the techniques of the Auditory-Verbal approach, may introduce the hand cue to the child’s primary caregivers when deemed beneficial. It should not be used by school classroom teachers and friends but mainly by parents or other key caregivers in a child’s environment. When acoustics are less favourable then a child with hearing impairment he/she will need to use visual cues and body language to supplement hearing, as does a typically hearing individual. Many speech/language pathologists have found the hand cue useful in highlighting listening in certain cases of children with normal hearing.
“CAN TECHNIQUES OTHER THAN THE HAND CUE BE USED TO EMPHASIZE HEARING?”
Yes! The primary caregiver should sit beside the child, close to the microphone of the better ear with the hearing technology. The closer they are to the child’s ear the softer the voice to ensure the opportunity to hear the less salient speech sounds. Vowels are louder than consonants and often mask a child’s hearing of the softer consonants. This is often evident in a child’s speech when consonants are deleted or substituted. No hand cue is necessary with preferential seating unless the child is actively searching for visual cues.
The therapist or teacher can suggest that the older child turn away to emphasise listening. This helps the child attend to the listening task and to concentrate on what is heard.
“WHEN DO YOU STOP USING A HAND CUE?”
When a child has a natural listening interaction, a hand cue is not necessary. However it is useful to continue using auditory techniques to gain a higher level of auditory learning such as listening in noise, talking on the telephone and overhearing conversations. Many an adult with hearing loss seeks further therapy to practise and enhance their auditory skills. The greater the skills in listening the greater the ability to monitor one’s voice and speech quality. This explains why effective auditory-verbal listeners usually have natural sounding speech.
2. ACOUSTIC HIGHLIGHTING
The earliest form of acoustic highlighting used is called “Motherese” or “Parentese.” It is speech used by parents/caregivers in talking with young children to make speech more audible to help them in learning language. Research by Dr. Patricia Kuhl indicates that parentese is universal and plays a vital role in helping infants analyse speech. The use of early highlighting is an auditory technique that is extended in communicating with the beginning hearing aid or cochlear implant user to increase the audibility of language. As a child learns to listen, the aim is to progress towards a more normal, less highlighted mode of communication.
Examples of acoustic highlighting are as follows:
MORE AUDIBLE progressing to LESS HIGHLIGHTING
(for a beginning child) (for a child who is listening well)
No background noise Increased background noise
6” from hearing aid or Increased distance from
C.I. hearing aid or C.I.
Simpler language with Complex sentences
shorter phrases
Greater acoustic contrast Less varied acoustic contrast
(vowel variation, rhythm and syllable (minimal pairs, similar rhythm)
contrast)
Emphasis on key words No emphasis on key words
Emphasis on words not accentuated, No emphasis
(prepositions, articles, verb tenses,
pronouns)
Word position in sentence:
End of sentence Middle Beginning
Closed set Open set
Slightly slower rate Normal rate
Increased pitch variation Normal rhythm
and rhythm
(sing what you say)
Clearer enunciation Less clear and/or unfamiliar
(use of “clear” speech) voice
Increased repetition No repetition
© Judith I. Simser
However, having reached the goal of less highlighting, it must be remembered that there are many noisy acoustic environments where acoustic highlighting may continue to be necessary just as it is with those who have normal hearing.
3. AUDITORY FEEDBACK
When children imitate or use spontaneous speech, they match their voice production with the speech patterns of others thus monitoring their own speech production. Besides this direct auditory feedback, children receive indirect feedback from the listener’s reactions to their vocalisations and speech, which further reinforces the quality of their production. In auditory directions, asking children to imitate what they heard, discourages guessing as it serves to verify what the children heard before attempting the task.
4. PAUSING AND WAITING
Children with hearing impairment may take longer to process auditory information, so the technique of pausing and waiting with anticipation encourages a child to listen and follow through with a task rather than waiting for the speaker to repeat.
When a child has developed some spoken language through hearing and is not attending well to auditory input he/she may respond to auditory input with “What?” or may sit there with a blank expression on his/her face. To emphasise listening, pause and then ask, “What did you hear?” This technique helps the child how develop clarification skills. You may discover that they have heard you and will respond appropriately or they will clarify by telling how much of the input they grasped.
5. NATURAL SEQUENTIAL DEVELOPMENT
In order to ensure success each child needs to progress through a hierarchy of listening, speech, language, cognitive and communication skills, much like a typical child. The Auditory-Verbal therapist develops targets based on a hierarchical model, (from most audible to least audible) and on normal stages of development in these areas. Input is provided primarily through audition. Only too often a child and his family experience failure because targets are too difficult and do not follow a natural sequential order. In developing speech through hearing, a developmental program is used. Initially, variations in vowel content and suprasegmentals offer good acoustic contrast aiding in speech perception. (See Appendix A-Suggestions for Highlighting Beginning Vocabulary). Speech babble is used to develop speech perception. As speech perception improves, there is a reciprocal benefit in speech production, Ling, D. (1987). Just as we repeat syllables in learning new words or a new language, so do we encourage the use of syllabic babble to heighten the auditory perception and production of speech sounds. Once a child produces targeted syllables, these phonemes must be reinforced in spoken language. Language targets follow a hierarchy of normal development but also of available acoustic cues.
In developing a listening function, there is a constant interplay of targets in listening, speech, language, communication and cognition in all interactions throughout a child’s day, with any variety of targets incorporated into any one event. Weekly targets are given to parents/caregivers and classroom teachers to co-ordinate efforts and to build upon listening basics. When parents integrate Auditory-Verbal techniques and targets into everyday, meaningful activities and experiences then their children have the best opportunity to develop good listening and language outcomes. Only once children have developed language can they then access school curricula.
LEARNING TO LISTEN
Guidance in creating a listening, learning environment is pertinent to the beginning stages, regardless of age.
Suggestions include some of the following:
• Enhance the acoustic environment by being close to the microphone of a child’s cochlear implant or the hearing aid of the better ear. Encourage listening by sitting beside a child, (not across), and focusing on objects in front of parent and child.
• Be aware of and minimise background noises especially the noise of an air conditioner, television, fridge or radio.
• This student is a BEGINNER. Assist a child by making speech more audible using parentese; that is, spoken language that is rich in suprasegmental qualities, repetitive in nature, initially focusing on low and mid-frequency vowel content, and in the context of short, meaningful two-to-three-word phrases.
• Throughout the day cue a child to “listen” while pointing to your ear to alert a child to attend to auditory input and meaningful environmental sounds. Observe a child’s listening and responding behaviours such as cessation of movement, eye contact to an object or person, imitation of a sound or a response indicating listening through body posture.
• Follow a child’s interest level in age and stage appropriate activities and experiences with specific targets integrated.
• Reinforce the expectation that with Auditory-Verbal techniques a child will learn to listen
THE ONGOING ASSESSMENT FORM
The following form presents hierarchies in the areas of audition, language, speech, cognition and communication although it is by no means complete. It serves as a quick evaluation form, as a diagnostic tool to help in setting ongoing targets and as a means to discuss progress with parents.
SIMSER AUDITORY-VERBAL ONGOING ASSESSMENT FORM
© Judith I. Simser
Name: DOB: Date started A.V.:
Hearing loss: Hearing aid model or implant:
Key: Beginning ┴ Inconsistent + Consistent Expressive Use (Cross out check)
AUDITION
Ling 6 Sound Test: detection & identification m__ u__ a__ i__ sh__ s__ silence__
distance (12 cm. 50 cm. 1 m. 2 m.): m___ u___ a___ i___ sh___ s___
words in phrases: 1. vowels + syllables differ ___ 3. rhyming words ___
2. same consonant, vowels differ ___ 4. final consonants only differ ___
auditory memory: 1 __ 2 __ 3 __ 4 __ 5 __ items
identification of consonants by: manner ___ songs & rhymes ___
voicing___ auditory attention to extended
place___ conversations & stories ___
selection by description: closed set - stage 1. sound-word repeated ___ 2. identify by key words ___
3. include objects with similar characteristics ___ 4. begin levels 1 & 2 in open set
open set - stage 1. sound-word repeated ___ 2. identify by key words ___
3. complex description ___ 4. identify by questioning___
taped instructions and stories____ listening in noise ___ group conversations ___
LANGUAGE
dates:
Vocabulary (1st year only): comprehension ___ wds ___ wds ___ wds ___ wds
spontaneous use ___ wds ___ wds ___ wds ___ wds
---------------------------------------------------------------------------------------------------------------------
nouns: sound-word ___ subject nouns ___ object nouns ___ parts of objects ___
by description___ plural nouns, irregular ___ regular___
verbs: directives ___ present progressive ___ future ___ past tense ___ conditional ___
pronouns: mine ___ I ___ you ___ he ___/or she ___ they ___ him ___
her ___ them ___ his ___ hers ___ theirs ____ we ___ us___
it ___ our ___ yours ___ myself ___ who/whom ___
prepositions: up ___ down ___ in or on ___ under ___ behind ___ beside ___
in front ___ in/on ___ cont. with concept list ___
adjectives and adverbs: beginning list ___ concept list ___
negatives: no ___ not ___ don't ___ isn't ___ can’t ___ didn’t ___ wasn’t ___
conjunctions: and ___ not the ___ either-or ___ only ___ everything but ___
neither-nor ___ because ___ so ___ if ___ before ___ after ___
articles: a ___ the ___
questions: What's that? ___ What's he doing? ___ What's it for? ___
What happened? ___ How many? ___ What colour? ___ Where? ___
What's missing? ___ Who is it? ___ Why? ___ When? ___ How? ___
auxiliary questions: do ___ are ___ is ___ can ___ does ___
examples of spoken language (bracket missing parts of speech) i.e., Daddy(‘s) car no (won’t) go.
date _________________________________________________________________________
date _________________________________________________________________________
SPEECH
voice quality (low 1- 5): ___ speech intelligibility (1-5): in context ___ out of context ___
suprasegmentals: duration: long ___ short ___ varied ___
intensity: loud ___ soft ___ varied ___
frequency: high___ low ___ varied ___
vowels: u___ a___ o___ æ ___ - i ___ ʌ ___ ɑ __ ɛ ___ - ʋ ___ e ___ ɝ ___ ɔ ___ ɪ ___
vowels alternated: u-a ___ a-u ___ - i-a ___ e-i ___
diphthongs: (ow) aʋ ___ (eye) aɪ ___ (aye) eɪ ___ (oy) ɔɪ ___
consonants: level 1 - p ___ b ___ m ___ h ___ w ___
level 2 - t ___ d ___ n ___ f ___ v ___ (sh) ʃ ___ ʒ ___ r ___ (y) ј ___
level 3 - k ___ g ___ l ___ (ng) ŋ ___ s ___ z ___ (th) θ ___ (th) ð ___
unreleased plosives _________________________
affricates: (ch) ʧ ___
(dg) ʤ ___ Adapted from Ling, D. (2002). Speech and the hearing impaired child:
Theory and Practice. 2nd Edition. Washington, DC:
Alexander Graham Bell Association for the Deaf.
blends: word initial – sequential ____________ coformulated _____________ complex blends ______
word final – continuant-continuant ___ continuant-stop ___ stop-continuant___ stop-stop ___
COGNITION
sorting: identical objects ___ categories ___ by function, shape, colour, number, texture, content
go togethers: real objects ___ cards or puzzles___ colours: red ___ blue ___ green ___ yellow ___
rote counting: 1-10 ___ number concepts: 1-3 ___ 4-6 ___ 7-10 ___ 11-20 ___ no. after___ no. before___
no. in-between ___ count by twos, threes ___ addition by one ___ by twos ___ subtraction by one___ create equal sets___ number stories ___
shapes: circle ___ square ___ star ___ triangle ___ rectangle ___
textures: soft ___ rough ___ continue concept list ___
comparisons: same___ different ___ doesn't belong ___ how alike ___ categorise and give reasons why ___
sequencing: shapes ___ colours ___ patterns ___ 2-4 pt. story ___ events ___ tell story __ multiple endings__
identity of an object ___ opposites ___ analogies ___ inferences ___ synonyms ___
double meanings ___ simple jokes ___ riddles ___ idioms ___
COMMUNICATION
has appropriate eye contact ___
practises turn taking ___ uses courtesy language: e.g., bye, I'm sorry, excuse me ___
initiates interactions ___ uses questioning ___
initiates conversational topics ___
repair strategies: asks for repetition ___ uses appropriate topic transitions ___
verifies partial information ___ shares conversational control ___
asks for clarification ___ provides clarification ___
maintains topic: 1 turn ___ 2 turns ___ 3 turns ___ extends conversation ___
NOTES:
© Judith I. Simser
AUDITORY MEMORY DEVELOPMENT
The items underlined indicate examples of the items a child needs to identify to understand the directions or information.
*Develop ability to follow a one-item memory task:
1. containing repetition of sound-word association in phrases, e.g.” The ball goes bounce, bounce, bounce.”
2. in single repetition of a sound-word association, e.g.” Where’s the cat that goes meow?”
3. in single objects representing nouns, verbs, adjectives and common phrases with varied suprasegmentals and vowel content, e.g. “Pick the flower” vs. “Wash, wash, wash your hands” vs. “Mmm, that’s good.”
4. in single objects varying in vowel content and syllables, e.g. “Where’s the spoon?” vs. apple vs. ice cream cone.
5. with word presented at end of sentence, e.g. “Please get the bananas.”
6. with word presented in middle or at beginning of sentence to prepare for two item memory, e.g. “Please put the bananas on the table,” while the speaker is pointing to the table.
Develop the ability to respond to two-item memory phrases:
1. two nouns, e.g. “Get your shoes and your hat.”
2. noun and verb, e.g. “The baby is sleeping.”
3. verb and object, e.g. “Wash the car.”
4. two verbs, e.g. “Jump and sit down.”
5. adjective and noun, e.g. “Go get your blue shirt.”
6. number and noun, e.g. “I want three candies.”
Develop the ability to process a three-item memory task:
1. three nouns, e.g. “Don’t forget your running shoes, your coat and your books.”
2. two nouns and a verb, e.g. “The boy and the dog are running.”
3. noun, and two verbs, e.g. “Daddy is washing and then having supper.”
4. noun, preposition and object, e.g. “Put your umbrella under your chair.”
5. two nouns and a conjunction, e.g., “You can have either an apple or a banana.”
6. two adjectives and a noun, e.g., “Make a big, brown tail.”
7. Pronoun, verb and object, e.g., “She is cutting the bread.”
Develop auditory memory tasks of four-to-five items:
1. four nouns, e.g. “When we’re shopping, we need bread, ice cream, fruit, and crackers.”
2. nouns, preposition and object, e.g. “Put your shovel and your bike behind the house.”
3. noun, conjunction, preposition and object, e.g., “Get some popcorn or some chips and put them beside the TV.”
4. two noun-verb phrases, e.g., “The boy is swinging and the girls are sliding.”
5. add a descriptive phrase, e.g., “See the lady wearing the blue dress in front of the store?”
6. add a time factor, e.g., “After you do your homework for one hour, you can watch TV.” “Before you wash your hands , you need to clean your black shoes.”
The above memory tasks can be practised in real life but also in contrived play by using toys for role-playing. Try to integrate memory tasks into daily living rather than making them task oriented.
SELECTION BY DESCRIPTION
A child begins to listen to longer information by identifying known vocabulary by its description in a closed set (where a choice of objects is visible to the child). Begin after the child has about a two-item memory.
1. where a known word or object representing a sound-word is used repeatedly, e.g. “It flies, up, up, up in the sky, it goes ah….ah, you ride in it.” “What is it?” Use a choice of four objects of different categories and all known vocabulary. For example, a shoe, a ball, a car and a dog.
2. identify an object by attending to a single repetition of familiar key words in the description, e.g., “It has four legs, it swims in the water, it hops and it is green. What is it? All characteristics in the choice of objects should vary.
3. include some objects that have a few similar characteristics, e.g., a bird and an airplane both fly; a fish and a frog both swim in the water.
4. *begin open set descriptions beginning with steps 1 and 2 above.
EXAMPLES OF BEGINNING LANGUAGE TARGETS DEVELOPED CONCURRENTLY WITH LISTENING, SPEECH, COGNITION & COMMUNICATION
- pronoun development, (“I, you, your, mine”)
- comprehension and use of prepositions (“in” or “on”) vs. (“under” or “behind”) in games, in cooking and eating activities, in creating crafts
Once a child develops phrases, record examples of child’s language and bracket the missing words so that these can be targeted and reinforced in future play activities and routines. For example, “I walk(ed) (to) the store (with) Mummy.” “Daddy(’s) car no (won’t) go!”
SPEECH DEVELOPMENT
In developing speech through hearing, a developmental rather than remedial program is used. Speech babble is used to develop speech perception. As speech perception improves there is a reciprocal benefit in speech production, Ling, D. (1997). Just as we repeat syllables in learning new words or a new language, so do we encourage the use of syllabic babble to heighten the auditory perception and production of speech sounds. Segments of therapy will involve practise in identifying early emerging phonemes such as vowels [a], [u], [o] and [i] and consonants [b], [m], (sh) and whispered [p] and [h]. Initially do not combine [u] with [m] as these will sound too similar to the beginning listener. The young child can practise phoneme perception by playing with objects with the above phonemes as associated sounds, (see Appendix A) and the older child can listen to identify them by their phonetic equivalents. When phonemes are identified, encourage production in syllabic babble and once achieved, phonemes should be transferred into phonology. Suggestions to develop intelligible speech include the following:
• listen carefully to a child’s speech to analyse speech errors rather than lip-reading him/her.
• in all speech techniques attempt to elicit a phoneme through hearing first. If a visual or tactile cue is used, once the child produces the sound, have him/her say it repeatedly using hearing only for auditory feedback to occur.
• when phonemes are missing, distorted or substituted, soften voice, get close to the implant or hearing aids and acoustically highlight the defective phoneme in syllabic babble. Once well produced in syllabic babble, transfer to phonology.
• continue to improve the suprasegmental qualities of speech. To aid in intelligibility emphasise rhythm in word groupings to create short phrases. For example, “My sister…went to school…on the school bus.”
• as a child progresses, use less acoustic highlighting with goal of more normal speech reception and production.
APPENDIX A
SUGGESTIONS FOR HIGHLIGHTING BEGINNING VOCABULARY
Vehicles
boat - p-p-p (unvoiced) car - b-r-r-r (truck)
airplane - a-a-a train - oo-oo-oo bus - bu-bu-bu
Animal sounds
cow - moo dog - bow-wow horse - neigh
cat - meow lamb - ba-a-a fish - swish
pig - oink frog - hop-hop-hop chicken - cluck
bird - chirp duck - quack-quack monkey - ee-ee-ee
owl - hhoo lion - rroar-rroar bear - grr-grr
Action Words Adjectives Nouns
push-push it down that’s hot the watch goes tic-toc
mmm- smell the flower it’s all gone hi baby
wake-up it’s dirty I’m Mummy, Daddy
pop-pop the bubbles it’s soft that’s my shoe
sh-h go to sleep it’s broken slide-up, up, up wee-e
sit down it’s wet that’s my eye, nose, mouth
wash-wash your hands it’s sticky look at the fish
have a drink the clown says ha ha ha
blow-blow the feather Santa says ho ho ho
walk-walk-walk Pronouns
bounce-bounce the ball
go-up-up-up (stairs and lift me up) that’s mine
it goes round and round give it to me
cut-cut....cut the banana
brush your hair, teeth
jump, jump, jump
Common Phrases
bye-bye no-no-no, don’t touch stop it
look at that uh-oh it fell down brr that’s cold
it’s too heavy that’s pretty help me
ow, it’s sore m-m-m that’s good I want more
I want a ______ what a mess pick it up
that’s funny wait a minute
© Judith I. Simser
REFERENCES
Auditory-Verbal International. (1991). Guiding principles. Auricle. Fall Vol.3. Alexandria, VI.
Bromwich, R. (1981). Working with parents and infants. Baltimore, MA: University Park Press.
Cole, E. (1992). Listening and talking: A guide to promoting spoken language in young hearing impaired children. Washington, DC: Alexander Graham Bell Association for the Deaf.
Estabrooks, W., Editor, (2001). 50 FAQ About AVT, Toronto, Ont.: Learning to Listen Foundation
Estabrooks, W., Editor, (1994). Auditory-verbal therapy for parents and professionals, Washington, DC: Alexander Graham Bell Association for the Deaf.
Flexer, C. (1999), Facilitating hearing and listening in children. (2nd Ed.). San Diego, CA: Singular Publishing Group
Goldberg, D.M &. Flexer, C. (1993) Outcome survey of auditory-verbal graduates: Study of clinical efficacy. Journal of the American Academy of Audiology, 4, 189-200.
Ling, D. (2002). Speech and the hearing impaired child: Theory and Practice. 2nd Edition. Washington, DC: Alexander Graham Bell Association for the Deaf.
Ling, D. (1989). Foundations of spoken language for hearing-impaired children. Washington, DC: Alexander Graham Bell Association for the Deaf.
Ling, D., & Ling, A.H. (1978). Aural habilitation: The foundations of verbal learning. Washington, DC: Alexander Graham Bell Association for the Deaf.
Luterman, D. (1999). The young deaf child. Baltimore, Maryland. York Press, Inc.
Pollack, D., Goldberg, D., & Caleffe-Schenck, N. (1997). Educational audiology for the limited-hearing infant. Springfield, IL: Charles C. Thomas (3rd Edition).
Simser, Judith, (1999). Parents, the essential partners in the habilitation of children with hearing impairment, in the Australian Journal of Education of the Deaf, Vol. 5, Adelaide, South Australia.
Simser, J.I. (1993). Auditory-verbal intervention: Infants and toddlers. The Volta Review, 95, (217-229).
Simser, J., & Steacie, P. (1993). A hospital clinic early intervention program. In A. Phillips & E. Cole (Eds.), Beginning with babies: A sharing of professional experience. Washington, DC: Alexander Graham Bell Association for the Deaf.
Stokes, J. (Ed.) (1999) Hearing impaired infants: Support in the first eighteen months. Washington, D.C. Alexander Graham Bell Association for the Deaf.
Talbot, Pam. (2002). Topics in Auditory-Verbal Therapy, Virginia, Auditory-Verbal International.
Lea’s favorite short SONGS
Lea’s favorite short SONGS:
AIRPLANE
Sing with toy airplane or picture of airplane:
Ahhhhhhhhhhhh
Ahhhhhhhhhhhh
Airplane flying high
Ahhhhhhhhhhhh
Ahhhhhhhhhhhh
Way up in the sky!
BUS
Sing with toy bus or picture of bus:
Bubu Bah Bubu Bah
Here comes the bus
Here come the bus
Bubu bah Bubu Bah
Coming for us
Coming for us
Sing with a toy car or picture of a car
Beep Beep Beep Beep
Beep beep Beep Beep
Mommy drives the car
Beep Beep Beep Beep
Beep Beep Beep Beep
A little red car
Toy train or picture of train
OO OO OO OO
Train goes down the track
OO OO OO OO
Now it’s coming back
Choo Choo!
Toy Boat or picture of boat
“PuPuPah PuPuPah
Listen Listen, do you hear the boat
“PuPuPah PuPuPah
Yes Yes, Yes I hear the boat.
With a toy clown or picture of a clown
Ha ha ha - ha ha ha
Funny little clown
Ha ha ha - ha ha ha
Walking all around!
Hear & listen! Talk & Sing! by W. Estabrooks & L. Birkenshaw-Fleming
AIRPLANE
Sing with toy airplane or picture of airplane:
Ahhhhhhhhhhhh
Ahhhhhhhhhhhh
Airplane flying high
Ahhhhhhhhhhhh
Ahhhhhhhhhhhh
Way up in the sky!
BUS
Sing with toy bus or picture of bus:
Bubu Bah Bubu Bah
Here comes the bus
Here come the bus
Bubu bah Bubu Bah
Coming for us
Coming for us
Sing with a toy car or picture of a car
Beep Beep Beep Beep
Beep beep Beep Beep
Mommy drives the car
Beep Beep Beep Beep
Beep Beep Beep Beep
A little red car
Toy train or picture of train
OO OO OO OO
Train goes down the track
OO OO OO OO
Now it’s coming back
Choo Choo!
Toy Boat or picture of boat
“PuPuPah PuPuPah
Listen Listen, do you hear the boat
“PuPuPah PuPuPah
Yes Yes, Yes I hear the boat.
With a toy clown or picture of a clown
Ha ha ha - ha ha ha
Funny little clown
Ha ha ha - ha ha ha
Walking all around!
Hear & listen! Talk & Sing! by W. Estabrooks & L. Birkenshaw-Fleming
Expereince Books Basics
Experience Books
By Lea Donovan Watson, MS, CCC-SLP, Certified AVT
Global Foundation for Children With Hearing Loss Vietnam Mobile Mission January 2011
An Experience Book is a way for parents and teachers to enrich their child’s language development. Like a scrapbook, this notebook includes concepts which the family wants the child to learn. Start with important people: Mom, Dad, grandparents, and siblings. Next, move to important toys, songs, places that the baby enjoys. Talk to the child at the appropriate language level for that child.. The key is to think, “What does this baby need to know now” and “How can I talk about what this baby need to hear at this point in development?”
In Auditory-verbal Therapy (AVT), children who are deaf and hard of hearing need to learn how to listen and then review what they heard. These scrapbooks provide a way for parent-child interchange.
Be thinking; “I need to help my baby hear. What is most important for the baby to hear? I am patterning this little brain for sound. How do I attract the baby’s attention with my voice?” Sitting close to the baby’s hearing aid or cochlear implant microphone as you talk you are establishing a pattern, a reaction, a style without even thinking about it. Pay attention to sound and expect the baby to respond to what you say.
Auditory-Verbal Therapy advocates an individualized hierarchy of auditory skills for learning to listen. The idea is to help each family implement the Ten Principles of Auditory-Verbal Practice* into their life. In each therapy session, the Auditory-Verbal Therapist makes thoughtful suggestions to the parent regarding the listening and language needs of the child. The parents are encouraged to add drawings or pictures during the week. Review of goals and objectives are right on the table as the baby and parent literally look at and talk about the story of their lives
The delight shared among the child, the parent, and teacher as they examine the book is exciting. “Daddy got a new pair of glasses!” the teacher exclaims as if she has just won the lottery. “Daddy glasses”; the child volunteers and beams with pride.
The mom talks more about the color, size, shape of the glasses, whether or not the child has glasses, mom wears glasses, or the teacher has glasses. The communication connection between the child and adults is charged with delight, magnetism, and auditory expectation.
Talking without lip-reading possible, sitting beside the child or with the mouth hidden either behind the book or with a hand, makes this auditory. The idea is: “auditory information to the brain first” allowing the hearing aids to work most effectively by making sure that was how the brain processed the incoming message. The parent radiates with joy to see their child who was deaf, listening. Expecting the child to listen and learn in this auditory-only way gives the parent and teachers a way to practice. The interaction is contagious because there are appropriate expectations made.
Choosing the type of book is an important first step. Some like the small size. Experience Books look like ‘flip books’. Cut photos of family members and close friends (including the teacher).The child responds to the auditory expectation of mom asking him the question “Where’s Daddy?” by looking directly at the picture of daddy.
Early on in therapy, I ask people to choose five songs to focus on with their baby – using toy props. Put photos of these very toys into the Experience Book.
Experience Book help parents be sure their child is listening to them and learning all the important baby language. Included pictures of animals, vehicles, seasonal concepts, that related to the Listen, Hear, Talk, and Sing* songs that are easy to sing.
Cardboard-type books or photo albums work best for the very young infant. I let the parents choose – notebook or sketchbook, but if they wait too long, I will start a book for them.
Add pictures of the Ling Sound Test. These sounds represent the frequencies needed to hear across the range of sound for speech to be accessible. It is very important that we know the baby can hear at these levels. We expect the baby who is deaf or hard of hearing to rely on their sense of hearing to process what we say. They use hearing aids or cochlear implants to access sound, but they need to be expected, guided, and reinforced for using their hearing just as any baby does. On each page I use markers to sketch or trace the object representing each sound;
an airplane for ‘ah’, a top for the humming sound ‘mmm’, an owl for ‘ooo’, a monkey for ‘eee’, a fish for ‘sh’, a snake for “s”.
That gets the parents going. Parents can use pictures of what they child likes. “See the birds that go tweet tweet and there’s the duck that goes quack quack, oh, look at the kitty cat, so cute, meow meow”.
“Oh, smell the pretty flowers!”.
“The teddy bear has a blue hat”.
“This card is from grandmother. See grandmother? That’s grandmother in the picture with you. Grandmother loves you.”
Parents are able to enjoy their book and realize their child learns to increase her auditory attention span and hear the familiar language they want to teach her. We keep adding pictures in each session building the book together. Parents might need help with the book. I see the book as an integral part of the therapy process even if much of it is created together in our sessions. As the Auditory-Verbal Therapist, I needed to review what we had talked about last week and be sure these parents had the tool to practice what we will be talking about at the next session.
The goal is to make language a salient part of all experiences a child encounters and to record it in a visual log book. Feeding in language is so important in the early months of language learning. The Experience Book assists family members and others to make language meaningful and fun.
Another parent clarifies; “One thing I really learned using the experience Book was not to ask my son so many questions, just comment. My son likes to look out the window. He saw the moon at night and I drew that in the book. Looking at the picture later, I commented that we saw the moon in the sky out the window. He said ‘moon sky’ and I followed his comment with; “Yes, you saw the moon in the sky. It was dark out. We saw the big round moon way up, up, up, high in the sky.
Kerry Dowling used the Experience Book to help her daughter, Hadley, learn to listen and develop language as I guided them in Auditory-Verbal Therapy from when Hadley was 6 months old. Kerry’s story about how she got started and chronicled Hadley’s listening and language development using Experience Books follows..
Experience Books
By Kerry Dowling – Hadley’s mom
We learned of Experience Books at our very first Auditory-Verbal Therapy session. Lea mentioned how important they are throughout these early years to encourage and sustain strong language development. I quickly put together a photo album of Hadley’s relatives, favorite activities, and prized toys. That was a good way to get started.
Hadley’s first Experience Book was started at age 13 months. Everything Lea first told me about Experience Books has come true. Hadley loves to read and reread her books, taking great delight in discussing the pictures and reliving fun memories. She has favorite pages that she returns to again and again. These Experience Books have hammered language into Hadley’s being, helping words and ideas gel in her brain and generate clear and concise language. Experience Books have become the most important tools we have used in two years of auditory-verbal therapy.
I compiled a list of things that have helped me:
Develop your books around themes. Our earliest books just end whenever we ran out of pages and needed to start another book. After a while, I opted to do a seasonal theme and have since created these books around Spring (March – May), Summer (June – August), Fall (September – November) and Winter (December – February).
Keep a list handy for ideas. There are days when I will be at a loss about what to include in the day’s entry. Some days, I have so many ideas that I can’t use them all. I keep a list (actually, a few of them!) where I jot down ideas to remind myself: that Hadley discovered that some music is sung and some only has instruments; that she was a good friend to someone who was angry; that she told a joke.
Save things! Anything that is mailed to Hadley eventually finds its way into the book. We include tickets, receipts, leaves, drawings, pictures, artwork—anything that Hadley finds interesting or important enough to comment on. We spend a lot of money on double-sided tape.
Involve the child. Around 2, we began asking Hadley what she thought was the favorite part of her day. On busy days, we’d ask her to be specific about the favorite part of a certain activity. Usually, we can use her answer to create the day’s entry in the book.
Share the responsibility. The experience book should not be something that just one parent does. The experience book is such an important tool that you don’t want to risk it becoming a chore. Share the wealth and find a way for both parents to contribute.
Focus on AV goals. While many of the entries are based on events in Hadley’s life, large and small, we also use some days to focus on a short-term goal, like the articulation of a certain sound or learning to categorize objects.
Focus on parenting goals. Once I realized how important these books were to Hadley, I found ways to use them for my own purposes. We have included entries on how to be a good friend, bad behavior, what to do when you have a cold, and how to wash your hands. We’ve also highlighted good decisions and behavior: the day Hadley took her medicine all by herself or chose to speak calmly instead of screaming. It still amazes me how reading about herself and talking about the entry helps promote the desired behavior.
You do not need to be the world’s best artist. You do not need to labor over each entry. If your drawings are unidentifiable, just label underneath. Your child will learn to distinguish one stick figure from another.
Ultimately, these books are for your child. Pages will rip; just tape them up. Pictures may be scribbled upon; just talk about how once a picture is complete, we don’t add to them again. A page may even be torn out. It doesn’t matter. Your child will still love to read the experience book.
Record those heartbreaking moments. My favorite entry is a drawing I did of a bright full moon rising over a pond, where the moon is just over the tops of tall pine trees. Hadley noticed the moon on a drive home one night and we talked about it for 20 minutes. It’s a moment that we may have otherwise forgotten, but now whenever she sees a full moon, Hadley reminds me of that one night.
It’s all about talking. It doesn’t matter what you say about each entry when reviewing them with your child for the umpteenth time. Your child will learn about the nuances of language if you talk naturally about each one. How boring if you always say the exact same thing on each page. This isn’t a story! Ask questions of your child. Mention a memory you have of that same experience. Use it as a way to launch into an activity. Let them do the reminiscing.
The Experience Book is a great early reading tool. Write clearly and carefully so your child isn’t trying to translate your scrawl. When your child begins to sight read, use the known words in the Experience Book to reinforce the learning.
The Experience Book has been an integral part of Hadley’s development. I really can’t think of another tool that we have used that has been more effective in developing and fine-tuning language themes for her.
By Lea Donovan Watson, MS, CCC-SLP, Certified AVT
Global Foundation for Children With Hearing Loss Vietnam Mobile Mission January 2011
An Experience Book is a way for parents and teachers to enrich their child’s language development. Like a scrapbook, this notebook includes concepts which the family wants the child to learn. Start with important people: Mom, Dad, grandparents, and siblings. Next, move to important toys, songs, places that the baby enjoys. Talk to the child at the appropriate language level for that child.. The key is to think, “What does this baby need to know now” and “How can I talk about what this baby need to hear at this point in development?”
In Auditory-verbal Therapy (AVT), children who are deaf and hard of hearing need to learn how to listen and then review what they heard. These scrapbooks provide a way for parent-child interchange.
Be thinking; “I need to help my baby hear. What is most important for the baby to hear? I am patterning this little brain for sound. How do I attract the baby’s attention with my voice?” Sitting close to the baby’s hearing aid or cochlear implant microphone as you talk you are establishing a pattern, a reaction, a style without even thinking about it. Pay attention to sound and expect the baby to respond to what you say.
Auditory-Verbal Therapy advocates an individualized hierarchy of auditory skills for learning to listen. The idea is to help each family implement the Ten Principles of Auditory-Verbal Practice* into their life. In each therapy session, the Auditory-Verbal Therapist makes thoughtful suggestions to the parent regarding the listening and language needs of the child. The parents are encouraged to add drawings or pictures during the week. Review of goals and objectives are right on the table as the baby and parent literally look at and talk about the story of their lives
The delight shared among the child, the parent, and teacher as they examine the book is exciting. “Daddy got a new pair of glasses!” the teacher exclaims as if she has just won the lottery. “Daddy glasses”; the child volunteers and beams with pride.
The mom talks more about the color, size, shape of the glasses, whether or not the child has glasses, mom wears glasses, or the teacher has glasses. The communication connection between the child and adults is charged with delight, magnetism, and auditory expectation.
Talking without lip-reading possible, sitting beside the child or with the mouth hidden either behind the book or with a hand, makes this auditory. The idea is: “auditory information to the brain first” allowing the hearing aids to work most effectively by making sure that was how the brain processed the incoming message. The parent radiates with joy to see their child who was deaf, listening. Expecting the child to listen and learn in this auditory-only way gives the parent and teachers a way to practice. The interaction is contagious because there are appropriate expectations made.
Choosing the type of book is an important first step. Some like the small size. Experience Books look like ‘flip books’. Cut photos of family members and close friends (including the teacher).The child responds to the auditory expectation of mom asking him the question “Where’s Daddy?” by looking directly at the picture of daddy.
Early on in therapy, I ask people to choose five songs to focus on with their baby – using toy props. Put photos of these very toys into the Experience Book.
Experience Book help parents be sure their child is listening to them and learning all the important baby language. Included pictures of animals, vehicles, seasonal concepts, that related to the Listen, Hear, Talk, and Sing* songs that are easy to sing.
Cardboard-type books or photo albums work best for the very young infant. I let the parents choose – notebook or sketchbook, but if they wait too long, I will start a book for them.
Add pictures of the Ling Sound Test. These sounds represent the frequencies needed to hear across the range of sound for speech to be accessible. It is very important that we know the baby can hear at these levels. We expect the baby who is deaf or hard of hearing to rely on their sense of hearing to process what we say. They use hearing aids or cochlear implants to access sound, but they need to be expected, guided, and reinforced for using their hearing just as any baby does. On each page I use markers to sketch or trace the object representing each sound;
an airplane for ‘ah’, a top for the humming sound ‘mmm’, an owl for ‘ooo’, a monkey for ‘eee’, a fish for ‘sh’, a snake for “s”.
That gets the parents going. Parents can use pictures of what they child likes. “See the birds that go tweet tweet and there’s the duck that goes quack quack, oh, look at the kitty cat, so cute, meow meow”.
“Oh, smell the pretty flowers!”.
“The teddy bear has a blue hat”.
“This card is from grandmother. See grandmother? That’s grandmother in the picture with you. Grandmother loves you.”
Parents are able to enjoy their book and realize their child learns to increase her auditory attention span and hear the familiar language they want to teach her. We keep adding pictures in each session building the book together. Parents might need help with the book. I see the book as an integral part of the therapy process even if much of it is created together in our sessions. As the Auditory-Verbal Therapist, I needed to review what we had talked about last week and be sure these parents had the tool to practice what we will be talking about at the next session.
The goal is to make language a salient part of all experiences a child encounters and to record it in a visual log book. Feeding in language is so important in the early months of language learning. The Experience Book assists family members and others to make language meaningful and fun.
All along the therapy process this is a tool for expanding language and refining listening skills while focusing on the child’s written goals and objectives such as:
- Language levels (labeling, combining words, semantic relations, using phrases)
- specific auditory skills; discrimination of animal sounds (great for vowel development);
- similar sounding words (in English: elevator/alligator; scoop/soup)
- enhancing language through concept development
- emotions; someone crying and talk about why they are sad or mad or confused
- vocabulary expansion (when the child uses a word think of another way to say it)
- syntax (using complete sentences with words in correct order)
- grammar (scene using he, she & they; past tense pictures or what will happen)
- semantics (meaning of what you want to say)
- speech sound development in natural context (a page of /p/ words)
- real world connections; places, books, likes, dislikes, general knowledge
Another parent clarifies; “One thing I really learned using the experience Book was not to ask my son so many questions, just comment. My son likes to look out the window. He saw the moon at night and I drew that in the book. Looking at the picture later, I commented that we saw the moon in the sky out the window. He said ‘moon sky’ and I followed his comment with; “Yes, you saw the moon in the sky. It was dark out. We saw the big round moon way up, up, up, high in the sky.
Kerry Dowling used the Experience Book to help her daughter, Hadley, learn to listen and develop language as I guided them in Auditory-Verbal Therapy from when Hadley was 6 months old. Kerry’s story about how she got started and chronicled Hadley’s listening and language development using Experience Books follows..
Experience Books
By Kerry Dowling – Hadley’s mom
We learned of Experience Books at our very first Auditory-Verbal Therapy session. Lea mentioned how important they are throughout these early years to encourage and sustain strong language development. I quickly put together a photo album of Hadley’s relatives, favorite activities, and prized toys. That was a good way to get started.
Hadley’s first Experience Book was started at age 13 months. Everything Lea first told me about Experience Books has come true. Hadley loves to read and reread her books, taking great delight in discussing the pictures and reliving fun memories. She has favorite pages that she returns to again and again. These Experience Books have hammered language into Hadley’s being, helping words and ideas gel in her brain and generate clear and concise language. Experience Books have become the most important tools we have used in two years of auditory-verbal therapy.
I compiled a list of things that have helped me:
Develop your books around themes. Our earliest books just end whenever we ran out of pages and needed to start another book. After a while, I opted to do a seasonal theme and have since created these books around Spring (March – May), Summer (June – August), Fall (September – November) and Winter (December – February).
Keep a list handy for ideas. There are days when I will be at a loss about what to include in the day’s entry. Some days, I have so many ideas that I can’t use them all. I keep a list (actually, a few of them!) where I jot down ideas to remind myself: that Hadley discovered that some music is sung and some only has instruments; that she was a good friend to someone who was angry; that she told a joke.
Save things! Anything that is mailed to Hadley eventually finds its way into the book. We include tickets, receipts, leaves, drawings, pictures, artwork—anything that Hadley finds interesting or important enough to comment on. We spend a lot of money on double-sided tape.
Involve the child. Around 2, we began asking Hadley what she thought was the favorite part of her day. On busy days, we’d ask her to be specific about the favorite part of a certain activity. Usually, we can use her answer to create the day’s entry in the book.
Share the responsibility. The experience book should not be something that just one parent does. The experience book is such an important tool that you don’t want to risk it becoming a chore. Share the wealth and find a way for both parents to contribute.
Focus on AV goals. While many of the entries are based on events in Hadley’s life, large and small, we also use some days to focus on a short-term goal, like the articulation of a certain sound or learning to categorize objects.
Focus on parenting goals. Once I realized how important these books were to Hadley, I found ways to use them for my own purposes. We have included entries on how to be a good friend, bad behavior, what to do when you have a cold, and how to wash your hands. We’ve also highlighted good decisions and behavior: the day Hadley took her medicine all by herself or chose to speak calmly instead of screaming. It still amazes me how reading about herself and talking about the entry helps promote the desired behavior.
You do not need to be the world’s best artist. You do not need to labor over each entry. If your drawings are unidentifiable, just label underneath. Your child will learn to distinguish one stick figure from another.
Ultimately, these books are for your child. Pages will rip; just tape them up. Pictures may be scribbled upon; just talk about how once a picture is complete, we don’t add to them again. A page may even be torn out. It doesn’t matter. Your child will still love to read the experience book.
Record those heartbreaking moments. My favorite entry is a drawing I did of a bright full moon rising over a pond, where the moon is just over the tops of tall pine trees. Hadley noticed the moon on a drive home one night and we talked about it for 20 minutes. It’s a moment that we may have otherwise forgotten, but now whenever she sees a full moon, Hadley reminds me of that one night.
It’s all about talking. It doesn’t matter what you say about each entry when reviewing them with your child for the umpteenth time. Your child will learn about the nuances of language if you talk naturally about each one. How boring if you always say the exact same thing on each page. This isn’t a story! Ask questions of your child. Mention a memory you have of that same experience. Use it as a way to launch into an activity. Let them do the reminiscing.
The Experience Book is a great early reading tool. Write clearly and carefully so your child isn’t trying to translate your scrawl. When your child begins to sight read, use the known words in the Experience Book to reinforce the learning.
The Experience Book has been an integral part of Hadley’s development. I really can’t think of another tool that we have used that has been more effective in developing and fine-tuning language themes for her.
Auditory-Verbal Strategies
•Repeat exactly what the child says
•Whisper, sing, emphasize elements of syntax, segmental or suprasegmental info
•Ask – what did you hear? As precursor to repeating spoken stimuli
•Encourage and coach parent as primary model
•Best listening conditions
•Sit near better ear
•Speak close to child’s HA or CI
•Speak at regular volume
•Minimize background noise
•Use interesting speech –repetitive, rich in melody, expression, rhythm
•Acoustic highlighting
Children learn when actively engaged in relaxed meaningful interactions
•Teach through Parent and caregivers
•Diagnostic sessions
•One-one therapy focus
•Maximum use of hearing
•Teach child as part of a team pf professionals
•Move closer to microphone
•Rewording, provide alternatives, repeating previously heard info
•Waiting +/or pausing for responses
•Putting spoken language directly back into hearing after a required visual tactile or kinesthetic cue
•Hand cue -
What is the hand cue?
•Signals “listen intently”
•Used to assist child to integrate all 5 senses
•Adult covers her mouth
•Encourages listening
•Adult moves her hand toward the child in a nurturing way as a prompt for vocal imitation or signal turn taking
More AV Strategies:
•‘set the stage’ for listening
•Key word at end of sentence
•Key word in mid sentence
•Smiling with expectation
•Eye contact
•Leaning forward
•Talk about it before showing it
•Not touching child for attention
•Comment throughout play
•Auditory closure
•Changing task from open set to closed set
•Providing rhyming words
•Referring to a “hearing age”
What is "Waiting" in AVT?
Child might need time to process and respond to what he hears
Pause and give time for the child to hear you
Give a little pause before one very important word; “I want you to pick up your …pause…shoes.” Pause to signal changes to facilitate speech processing
•Whisper, sing, emphasize elements of syntax, segmental or suprasegmental info
•Ask – what did you hear? As precursor to repeating spoken stimuli
•Encourage and coach parent as primary model
•Best listening conditions
•Sit near better ear
•Speak close to child’s HA or CI
•Speak at regular volume
•Minimize background noise
•Use interesting speech –repetitive, rich in melody, expression, rhythm
•Acoustic highlighting
Children learn when actively engaged in relaxed meaningful interactions
•Teach through Parent and caregivers
•Diagnostic sessions
•One-one therapy focus
•Maximum use of hearing
•Teach child as part of a team pf professionals
•Move closer to microphone
•Rewording, provide alternatives, repeating previously heard info
•Waiting +/or pausing for responses
•Putting spoken language directly back into hearing after a required visual tactile or kinesthetic cue
•Hand cue -
What is the hand cue?
•Signals “listen intently”
•Used to assist child to integrate all 5 senses
•Adult covers her mouth
•Encourages listening
•Adult moves her hand toward the child in a nurturing way as a prompt for vocal imitation or signal turn taking
More AV Strategies:
•‘set the stage’ for listening
•Key word at end of sentence
•Key word in mid sentence
•Smiling with expectation
•Eye contact
•Leaning forward
•Talk about it before showing it
•Not touching child for attention
•Comment throughout play
•Auditory closure
•Changing task from open set to closed set
•Providing rhyming words
•Referring to a “hearing age”
What is "Waiting" in AVT?
Child might need time to process and respond to what he hears
Pause and give time for the child to hear you
Give a little pause before one very important word; “I want you to pick up your …pause…shoes.” Pause to signal changes to facilitate speech processing
Daniel Ling says:
“Hearing is the most effective sensory channel for the development of spoken language – vision and touch maybe supplementary or complimentary channels.”
“Speech is an invaluable asset for the child who is deaf or hard of hearing and hence its development merits high priority.”
"Feedback is vitally important –Auditor Feedback LoopSpeech acquisition needs to be funPrevention of faults through systematic development is easier that their cure through remedial teachingNormal speaking models = normal speech patterns."
Perception and Production enhance each other:
•Reinforce each other
•Continuous, perceptible growth in the quantity and variety of sound patterns
“Speech is an invaluable asset for the child who is deaf or hard of hearing and hence its development merits high priority.”
"Feedback is vitally important –Auditor Feedback LoopSpeech acquisition needs to be funPrevention of faults through systematic development is easier that their cure through remedial teachingNormal speaking models = normal speech patterns."
Perception and Production enhance each other:
•Reinforce each other
•Continuous, perceptible growth in the quantity and variety of sound patterns
Aucoustic Highlighting
•Enhance the audibility of spoken language
•Move from most audible to least audible
•Move from known to unknown
••Every child has different quality & quantity of hearing
• Simser's 3 Es –
Easy to hear
Extensive experience through play
Expect child to hear them
•Move from most audible to least audible
•Move from known to unknown
••Every child has different quality & quantity of hearing
• Simser's 3 Es –
Easy to hear
Extensive experience through play
Expect child to hear them
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