Transcript Auditory Verbal Therapy

Author: Jack Slemenda
Converse College, SC
Date submitted to deafed.net – March
20, 2008
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Auditory Verbal
Therapy
Jack Slemenda
Converse College
Slide Contents
• I. Auditory Verbal Therapy (3-23)
• II. Cochlear Implants (24-32)
• III. Maintenance/Trouble Shooting for
Cochlear Implants (33-40)
• IV. Speech, Language, Cognitive and
Audition Evaluations (41-46)
• V. Expectations for a Child with a Hearing
Loss (47-55)
• VI. Lesson Plans/Treatment Goals (56-87)
All children have residual
hearing that can be
molded for functional use
History and Philosophy of
Auditory Verbal Therapy
What is AVT and where
did it originate?
• AVT was established as an approach
to therapy in the mid 20th century
by pioneers Ling, Beebe, and Pollack.
• Auditory Verbal International
established ten principles to guide
the field and foster understanding of
Auditory Verbal Therapy.
First AVT Principle
 Supporting and promoting programs for the early
detection, identification, and diagnosis of hearing
loss and the auditory management of infants,
toddlers, and children identified along with
Auditory-Verbal Therapy.
Second AVT Principle
• Providing the earliest and most
appropriate use of medical and
amplification technology to achieve
the maximum auditory stimulation
benefit.
Third AVT Principle
 Seeking to integrate listening as well as
maximal acoustic stimulation into the
child’s total personality in response to the
environment by guiding/coaching
caregivers without the use of sign language
or emphasis on speechreading.
Fourth AVT Principle
 Supporting the view that communication is
a social act, and seeking to improve spoken
communication interaction within the
typical social dyad of infant/child with
hearing loss and primary caregiver’s
including use of the parents as primary
models for spoken language development
and implementing one-on-one teaching.
Fifth AVT Principle
 Seeking to establish the child’s
integrated auditory system for the
self-monitoring of emerging speech.
Sixth AVT Principle
 Using natural sequential patterns of
auditory, perceptual, linguistic and
cognitive stimulation to encourage the
emergence of listening, speech, and
language abilities.
Seventh AVT Principle
Guiding and coaching parents to
create environments that support
listening/spoken language through
the child’s daily activities and to
integrate listening and spoken
language in the child’s life.
Eighth AVT Principle
Guiding and coaching parents to help
their child self-monitor spoken
language production.
Ninth AVT Principle
Making ongoing informal/formal
diagnostic evaluation and prognosis of
the development of listening skills as
an integral part of the rehabilitative
process.
Tenth AVT Principle
Supporting the concepts of
mainstreaming and integration of
children with hearing loss into
regular education classes with
appropriate support services and to
the fullest extent possible.
Why does AVT work????
• Existing Evidence Supporting the
AVT practice
The majority of children with hearing
loss have useful residual hearing… a
fact know for decades ( Bozold and
Slebenmann, 1908, Goldstein, (1939);
Urbantschitsch, 1982).
Why AVT cont…
When properly aided, children with
hearing loss can detect most if not
all the speech spectrum (Beebe,
1953;Goldstein, 1939; Johnson, 1976;
Ling and Ling, 1978; Pollack, 1970,
1985; Ross and Calvort, 1984).
Cont….
 Once all available residual hearing is accessed through
amplification technology (eg. Binaural hearing aids and
acoustically tuned earmolds, FM units, cochlear implants) in
order to maximum detection on the speech spectrum, then a
child will have the opportunity to develop language in a
natural way through the auditory modality.
 A child with a hearing loss need not automatically be a visual
learner.
 Hearing, rather than being a passive modality that receives
information, can be the active agent of cognitive
development (Boothroyd, 1982; Goldberg and Lebahn, 1990;
Robertson and Flexor, 1990; Ross and Calvert, 1984).
Cont…
In order to benefit from the “critical
periods” of neurological and linguistic
development, then the identification of
hearing loss, use of appropriate
amplification and medical technology, and
stimulation of hearing must occur as early
as possible (Clapton, and Winfield, 1976;
Johnson and Newport, 1989; Lenneberg,
1967; Marler, 1970; Newport, 1990).
Cont….
If hearing is not accessed during the
critical language years, a child’s ability to
use acoustic input meaningfully will
deteriorate due to physiological
(retrograde deterioration of auditory
pathways), and psychosocial (attention,
practice, learning) factors (Evans,
Webster, and Cullen, 1983; Merzenich and
Kass, 1982; Patchett, 1977; Robertson and
Irvine, 1989; Webster, 1983).
Cont….
Current information about normal language
development provides the framework and
justification for the structure of
Auditory-Verbal practice. That is
infants/toddlers/children learn language
most efficiently through consistent and
continual meaningful interactions in a
supportive environment with significant
caretakers (Kretschmer and Kretscher,
1978; Lennenberg, 1967; Leonard, 1991;
Ling, 1989; MacDonald and Gillette, 1989;
Menyuk, 1977; Ross, 1990).
Cont…
As verbal language develops through
the auditory input of information,
reading skills also develop (Geers and
Moog, 1989; Ling 1989, Robertson
and Flexor, 1990).
Rationale Cont…
 Parents in Auditory-Verbal programs do not have
to learn sign language or Cued Speech. More than
90% of parents with children with hearing loss
have normal hearing (Moores, 1987). Studies have
shown that over 90% of parents with normal
hearing do not learn sign language beyond the
basic preschool level of competency (LuetkeStahlman and Moeller, 1987). Auditory-Verbal
Practice requires that caregivers interact with a
child through spoken language and create a
listening environment which helps a child to learn.
Cont…

If a severe or profound hearing loss automatically makes
an individual neurologically and functionally “different”
from people with normal hearing (Furth, 1964; Myklebust
and Brutton, 1953), then the Auditory-Verbal philosophy
would not be tenable.
 The fact is however, that outcome studies show that
individuals who have, since early childhood, been taught
through the active use of amplified residual hearing, are
indeed independent, speaking, and contributing members
of mainstream society (Goldberg and Flexer, 1991; Ling,
1989, Yoshinaga-Itano and Pollack, 1988).
Cochlear Implants
Companies, Parts, Features
Cochlear Implants
• Nucleus 24 Contour
– Cochlear Corporation
• Clarion CII Bionic Ear
– Advanced Bionics
• Combo 40+
– Med-EL
NUCLEUS
• Processors
– SPrint (Body worn device)
• Rechargeable batteries
– ESPrit 3G (BTE)
• No rechargeable batteries
• Internal Device
– Nucleus 24 Contour
• 22 Electrodes
Nucleus 24 Contour
ADVANCED BIONICS
• Platinum BTE
• S-Series and Platinum Speech
Processor (body worn)
• All Rechargeable Batteries
HiRes 90K
Platinum Sound Processor
Platinum BTE Processor
Maintenance and Trouble
Shooting for Hearing
Aids and Cochlear
Implants
What to do if there is no
sound?
•
•
•
•
Battery may be dead
Battery may be in backwards
Hearing aid may be turned off
Sound outlet may be plugged with ear
wax
What to do if there is
weak sound?
• Weak battery
• Sound outlet or inlet may be plugged
with ear wax
• Current hearing condition may have
changed
What to do if there is a
crackling or frying sound?
• Volume may be set too high
• Object may be covering inlet such as
a hat, scarf, or coat collar
• Excessive wax present in the ear
• Instrument may not be fitted
correctly in the ear (contact
audiologist)
Trouble Shooting for
Cochlear Implants is Product
Specific
If the problem with the
hearing aid persists, it is
important to call the
audiologist right away!!
General Maintenance for
Hearing Aids
• Cleaning
• Storage
• Daily living
General Maintenance for
Cochlear Implants
•
•
•
•
Small children
Moisture
Batteries
Static electricity
Speech, Language,
Cognitive, and Audition
Evaluations
Testing with Hearing
Impaired Children
• Areas of testing:
– Language- Receptive and Expressive
– Articulation/Phonology
– Auditory Skills
Language
• Testing may include comprehensive
language tests, such as the CELF-P2,
CELF-4, PLS-4, CASL, CREVT-2,,
TELD:3,TOLD-P:3, or TOLD-I:3.
• Tests of expressive language and
vocabulary, such as, EOWPVT, EVT,
SPELT-3 or SPELT-P.
Language
• Tests of receptive language, such as
ROWPVT or PPVT-3.
• Screening tests: Rossetti InfantToddler Language Scale or the REEL3.
• Concept testing may also be
completed, using a test such as the
Bracken-R.
Articulation/Phonology
Articulation:
-GFTA-2
-CAAP
-Arizona 3
-SPAT-D
Phonology:
KLPA-2
HAPP-3
CAAP
Compton Assessment
IEPN
Auditory Tests
• Tests that focus on use of audition in
language:
–
–
–
–
–
–
–
–
TACL
TARPS
TAPS-R and TAPS-UL
ESP
APT-HI
IT-MAIS
MUSS
TAC
Expectations for a
Child with a Hearing
Loss
Chronological Age vs.
Cochlear Age
• Chronological age begins at birth
• Cochlear age begins when the implant
is activated
• Cochlear age used as tool
• Speech and language
expectations/development should be
based on cochlear age
Progression of
Development
• Normal speech and language
development can be expected on a
delayed time scale
• Speech and language goals should
follow the natural progression of
normal speech and language
development
Auditory Expectations with
AVT & CA @ 12 months
• Respond to a variety of
environmental and speech sounds at
various distances
• Imitate vowels and some consonants
• Imitate motions of nursery rhymes
• Identify nursery rhymes when sung
AVT & CA @ 12 months
cont.
• Respond to familiar phrases
• Identify and imitate learning to
listen sounds
Auditory Expectations with
AVT & CA @ 24 months
• Identify a picture that is part of a
simple story
• Identify an object with descriptors
• Recall 3 critical elements
• Answer questions about a picture,
book, or set of objects
Auditory Expectations with
AVT & CA @ 36 months
• Answer questions & recall details
about a story with the topic revealed
• Answer questions without pictures
• Recall four critical elements
• Answer questions about a familiar
topic
Auditory Expectations with
AVT & CA @ 48 months
• Repeat easy sentences
• Process information (by live voice or
on tape) at sentence and
conversation level with background
noise
• Follow a conversation with an
unrevealed topic
AVT & CA @ 48 months
cont.
• Retell a story recalling many details
in the correct sequence
Expectations taken from the Auditory Learning Guide (ALG)
developed by Beth Walker, 1995
Lesson Plans and
Treatment Goals
Sample Lesson Plan
GOAL
ACTIVITY
PROCEDURE
Sample target items
Materials
Audition:
Speech:
Language &
Cognition:
Other:
Rationale
Supporting
Research
STRATEGIES
(To promote auditory
learning)
HOME
IDEAS
EVAL/NEXT GOALS
Audition Goals &
Activities
• Detect/identify sounds of the Ling
6/7 Sound Test
“s” “m” “oo” “ee” “ah” “sh” “fff”
–
–
–
–
Fish in a fish bowl with water
Seeds in a flower pot
Animals in sand
Cars down a ramp
Audition Goals &
Activities
Learning to Listen Sounds
Cow
Ice cream
Car
Rabbit
Bus
Truck
moo moo
mmmmm
beep beep
hop hop
bubu
honk honk
Snake
Airplane
Toothbrush
Monkey
Fish
Ball
ssssss
ahhhh
chchchch
eeeee
shshshsh
bounce bounce
Audition Goals &
Activities
• Identify/imitate approximations of
Learning to Listen to Sounds
–
–
–
–
Scavenger hunt
Grab bag, surprise box
Open the “presents”
Guessing game with cups
Audition Goals &
Activities
• Follow directions by recalling three
critical elements
–
–
–
–
Barrier game
Coloring activity
Feed the people
Build a castle
Auditory Strategies
•
•
•
•
•
•
•
•
Move closer to the implant
Vary the prosody and intonation
Sing a song
Put the key word at the end of the phrase
Pause before saying the key word
Whisper voiceless sounds
Prolong fricatives and nasals /hausssss/
Repeat stops /kkkkeik/
Auditory Strategies
•
•
•
•
•
•
Vary the number of syllables
Decrease background noise
Ask “what did you hear?”
Auditory sandwich technique
Present two choices
Use the parent as a model
Speech Goals &
Activities
• Imitate consonants varying by manner with
the same vowels
ex: ssss vs tutu
mmm vs bubu
– Microphone
– Basketball, bowling, soccer
– Balloon toss
– Marbles
– Make a puzzle
Speech Goals &
Activities
• Produce /m/ in the initial position of
words
– /m/ magnets
– Hide /m/ objects in rice, beans, or sand
– Make a book
Language Goals and
Activities
A Review: Normal Language
Development Checklist
6 Months
Repeats self-produced sounds
Imitates sounds
Vocalizes to others
Uses about 12 different phonemes
Language Goals And
Activities
1 Year Old
Communication Development
 First true words 10-15 months
 Use of jargon 15-18 months
 Expressive Vocabulary 50 words-18
months
 Gestures and vocalizes wants and needs
 Develops object permanence
Language Goals and
Activities
1 Year Old
Vocabulary
 Turns to name
 Jabbers Loudly
 Waves “bye bye” upon request
 Plays “peek-a-boo”
 Often over-generalizes meaning (ball, dog)
Language Goals and
Activities
2 Year Old
 Jargon almost completely dropped out
 Pronouns are used often and correctly
 Vocabulary may have grown from 50-200
words
 Average sentence length 2.5 words
Language Goals and
Activities
2 Year Old
Vocabulary
 Understands 300-600 words
 Points to five body parts on command
 Responds to y/n questions appropriately
 Knows and uses prepositions “in” and “on”
 Names and produces sounds of common animals
 Follows simple directions
Language Goals And
Activities
2 Year Old
Grammar
 Speaks in 2-3 word utterances
 25% of two-word combo’s consist of noun
+ verb (Open-Pivot) construction (Daddy
go)
 Asks “What’s that?”
 Uses rising intonation with other
questions
Language Goals and
Activities
3 Year Old
 Talking in multi-word utterances
 Vocabulary is extensive and long
 Comprehensive of more complex
directions
 Concrete in regard to subjects they can
discuss
 The “why” question phenomenon
Language Goals and
Activities
3 Year Old
Vocabulary/Concepts
 Understand the meaning of “Who?”, “Why?” and
“How many?”
 Able to answer AGENT + ACTION?’s
 Knows own gender
 Understands basic adjectives “big” and “little”
 Counts up to 3 but only understand concept of
“one”.
 Follows 2-4 part commands
Language Goals and
Activities
3 Year Old
Grammar
 Speaks in 3-4 word sentences
 Articles “a” “the” and copula/auxiliary “is” are
beginning to be included.
 Use of word tense are present
 Use of pronouns “I”, “me”, “you”, “my”, “mine”
 Yes/no questions are developed “Is this a horse?”
 Over generalizes grammar rules
Language Goals and
Activities
4 Year Old
 Begin to play with words
 Elaborates simple responses into
long narratives
 Comments with approval on his/her
own behavior and criticizes that of
others
Language Goals and
Activities
4 Year Old
Vocabulary/Concepts
 Identifying and Expressing understanding of
colors
 Counts to ten by rote, understands concept of 3.
 Can perform simple analogies “fire is hot, ice
cream is ____”
 Understands basic prepositions
 Understands adjectives of size and quantity:
Language Goals and
Activities
4 Year old
Grammar
 4-5 word sentences, on average.
 Sentences are complete
 Grammatical overgeneralizations continue
 Uses third person singular
 Use of conjunctions
 Modal verbs
Language Goals and
Activities
5 Year old
 Has a sense of social standards and
limitations. (pragmatically appropriate
given then situations)
 Mastered number concepts thru 10
 Can name and describe use and function of
everyday objects
 Grammatical and articulatory errors are
eliminated
Language Goals and
Activities
5 Year old
Vocabulary Concepts
 Can group objects by category
 Aware of the function of senses (eyes, ears,
nose, mouth)
 Understands prepositions “behind” and ahead of”
 Understands “first” and “last”
 Understands the concept of time
Language Goals and
Activities
5 Year old
Grammar
 Sentences are from 5-6 words in length
 Can understand almost any type of
sentence spoken
 Speaks in grammatically complete, correct
sentences.
 Begins to develop metalinguistic
awareness
Language Goals and
Activities
6 Year Old
 Sentence Length- 6-7 words
 Vocabulary -5000-6000 words
 Number concepts- rote counting up
to 30
 Asks meaning of words
 Complete analogies
Language Goals and
Activities
Bloom and Lahey Overview
 Phases
 Content Categories
Language Goals and
Activities
HOW DO I TEACH LANGUAGE?....
Language Teaching Hierarchy
Language Goals and
Activities
Language Temptations:
**** Reminders:
Do's
 Remember Children need opportunities to communicate
 Deal with the child in a sensitive way
 Be aware of the child’s message
 Plan activities that mean something to the child through his
or her daily activities
 Involve other people in the interaction
 Remember having fun is a part
 Allow wait time … typically 10-15 seconds; for those
significantly impaired up to 30 seconds
Language Goals and
Activities
Don’t ’s
 Don’t rush the child’s attempts to communicate
 Don’t overload the child’s ability to see, hear, and move.
 Don’t set the child up to fail
 Don’t waste valuable time doing things with child that will
not help him or her in life
 Don’t assume you know what the child is trying to
communicate
Expectations taken from Wetherby and Prizant 1989
Communicative Temptations and Pamela Talbot 2002 Topics
in Auditory Verbal Therapy
See Communicative Temptations Handout
Language Goals and
Activities
Handouts: See sampling of activities
following phases 1-3 content
categories of Bloom and Lahey.
Note: Each activity can be modified to
accommodate learners at varying
phases of Bloom and Lahey.
Auditory Strategies
 Ask the child what did they hear; not are you
listening???
 Use the hand cue
 Move in closer
 Repeat whole phrase
 Acoustically highlight; not over-articulate
 Rephrase
 Whisper the key sound
 Model on the parent first