Transcript Modes of Communication

Modes of Communication
AUDIOLOGIC REHABILITATION FOR
CHILDREN
&
EDUCATIONAL AUDIOLOGY
SPA 6581 – SPRING 2015
LECTURE: JANUARY 19, 2015
“Although children who are deaf
are deprived of meaningful access
to spoken language, their brains
are fully equipped to acquire
language and they must be exposed
to it in meaningful ways (Ogden,
1996).”
Language
 Language is made up of socially shared rules that
include the following:




What words mean
How to make new words
How to put words together
What word combinations are best in what situations
 When a person has trouble understanding others
(receptive language), or sharing thoughts, ideas,
and feelings completely (expressive language),
then he or she has a language disorder.
Speech
 Speech = verbal means of communicating
 Speech consists of the following:

Articulation


Voice


How speech sounds are made
Use of vocal folds and breathing to produce sound
Fluency

The rhythm of speech
 When a person is unable to produce speech sounds
correctly or fluently, or has problems with his or her
voice, then he or she has a speech disorder
Social Language Use (Pragmatics)
 An individual may say words clearly and use
long, complex sentences with correct
grammar, but still have a communication problem
– if he or she has not mastered the rules for social
language.
 Pragmatics involves 3 major communication skills:
 Using language
 Changing language
 Following rules
Communication
 Fluent Communication
 Consists of sending and receiving linguistically encoded
messages
 Parent/Child communication can be used in order
to:

Enjoy, share, request, assist, inform, learn about the world
Communicative Interaction
 In order for communicative attempt by either
interactant (i.e., communicative partner) to be
successfully received, there are 2 necessary
conditions:

Shared focus

Message must be relevant to and interpretable by the listener
Spoken Language
Normally learned through hearing
When hearing is impaired, special means must be
devised for each child to learn language
Since every hearing loss is different, and ever child
learns differently, there is no single approach to
communicating the meaning of language that is best
for all children.
COMMUNICATION MODES
NAME SOME MODES OF COMMUNICATION!
Some Commonalities
 All the approaches/modes work toward developing




communication
All stress things like receptive language and
expressive language development
Most work on speech development
All work on reading skills
It is the degree of the parent’s involvement with
the program of choice that makes the greatest
difference.
Modes of Communication
Visual
Option
American
Sign
Language
(ASL)
Combined
Options
Auditory-Oral
Cued Speech
Auditory
Option
Total
Communication
Auditory
Verbal
Visual Option:
American Sign Language
 Characteristics
 Completely manual approach
 Bilingual approach to develop both ASL and English
 English as a second language
 Accessible to individuals with hearing loss, regardless of access
to audition
Visual Option:
American Sign Language
 Definition
 Visual/manual language
 Has its own grammar and linguistic properties
 Not based on English grammar or sentence structure
 Used within the Deaf community
ASL Primary Goals
 To establish ASL as primary language
 Visually introduce language for development internally
 Used as a basis for developing English as a second
language
 Develop a positive self-image, with regards to hearing
loss
 Communication, access, and the ability to identify with
the Deaf community
 May favor the individual’s choice to wear
amplification
ASL: Language Development
 Receptive language
 Develop early language concepts
 Developed as primary language through immersion
 Written English typically taught after development of ASL
 Expressive language
 ASL fluency along with written English
 May encourage speech outside the classroom environment
ASL: Hearing
 Individual decision regarding amplification is often
encouraged

What could this mean?
Timeframe? When is a child able to make this decision?
 Windows of opportunities?
 Child’s view of the audiological treatment?

ASL: Primary Caregiver Responsibility
 Provide constant access to deaf and/or hearing




adults and peers who are fluent in ASL
Become fluent in ASL so that EFFECTIVE
communication can occur
Model appropriate language through ASL
Interact with individuals who are deaf for parent
training
Learn about Deaf culture
ASL: Learning the Mode
 Courses
 Support groups
 ASL Books
 Practicing in public
 Developing fluency in order to constantly provide an
enhanced vocabulary model, which is slightly above
the current skills of the child
Visual Option:
American Sign Language
Beginnings Website – ASL
Beginnings Website – ASL
Beginnings Website – ASL
Lang.
regardless of
audition
May decrease
frustration
with inability
to effectively
communicate
ASL
Pros
May be useful
in situations
requiring
additional
access to
language
Can be
introduced
very early
Social and
Educational
Considerations
ASL primary
language, English
as a second
language, what
about primary
language of the
family?
ASL
Cons
To be effective,
family should
learn new
language
Grammar and
Syntax differs
from English
Disconnect with
“Hearing”
World/Audition
not typically
valued
Auditory Option: Auditory-Verbal
 Definition
 Used to develop spoken language through listening
 Requires aggressive audiological management
 One-on-one therapy
 Does not allow manual communication or speechreading
 Caregivers required to participate

Beginnings Website: Auditory-Verbal
A-V Primary Goals
 Utilize the following:
 Any residual hearing
 Appropriately fit amplification (HAs, FMs, CIs)
 Develop age-appropriate spoken language via audition only,
without the addition of visual cues
 Support inclusion in school and integration into
hearing community
A-V: Language Development
 Receptive language:
 Developed using audition
 Early, consistent, and developmentally appropriate therapy
 Visual strongly discouraged
 Expressive language:
 Spoken and written language
A-V: Hearing
 Personal amplification (early and consistent)
 Requires adequate residual hearing for skill
development with regards to spoken language
 Requires ongoing auditory management
A-V: Primary Caregiver Responsibilities
 Must incorporate language learning activities into
daily routines
 Use of sound as meaningful part of daily experience
and communication
 Participate in therapy sessions to learn strategies.
Use strategies learned at home on a consistent basis.
 Learn to create the optimal listening learning
environment
Auditory Verbal Video
AUDITORY VERBAL – CLIP 1
AUDITORY VERBAL – CLIP 2
AUDITORY VERBAL – CLIP 3
Aggressive
Audiological
Management
Research
indicates good
progress when
family and
patient adhere
to the program
AV
Pros
Does not
require a new
language to be
learned by
caregivers
Follows typical
spoken
language
development
Limited
availability of
specialized
therapists
May be
influenced
significantly
by
concomitant
factors
AV
Cons
Requires a
significant
amount of
family
commitment
Not typically
accepted by
the Deaf
community
A-V Case Study
 Patient B
 Severe to profound sensorineural hearing loss identified at
birth via NBHS and Follow-up
 Audiological Treatment: Fit with hearing aids at 2 months of
age
 Audiological Treatment: Cochlear implantation right ear at 1
year; cochlear implantation left ear at 2.5 years
 Therapeutic Approach and Communication Mode: Family
chose Auditory-Verbal
Combined Option: Cued Speech
 Definition
 Visual communication system
 Uses eight hand shapes in four positions
 Used in combination with natural mouth movements of speech
to aid in clarification of spoken language
 Demonstrates pronunciation of English words for every
spoken syllable
 Aids the development of verbal language, speech reading, and
speaking

Beginnings Website: Cued Speech
Cued Speech: Primary Goals
 Develop internal spoken language, communication skills,
and reading ability
 Uses combination of listening, specific visual cues and
speechreading
 Support inclusion in school
 Integration into the hearing community
 Support literacy
Cued Speech: Language Development
 Receptive Language:
 Early, consistent, and CLEAR communication
 Expressive Language:
 Spoken English
 Sometimes with expressive cues
 Written English
Cued Speech: Hearing
 Encourages early and consistent use of personal
amplification
 Develop maximum use of residual hearing
 Ongoing auditory management required
Cued Speech: Primary Caregiver Responsibilities
 MUST learn to cue fluently (all immediate family
members)
 Encourage use of amplification consistently
 Cue at ALL TIMES when speaking
 Develop skill and fluency through classes, practice,
and consistent use (may take a year)
Cued Speech Video
CUED SPEECH – CLIP 1
CUED SPEECH – CLIP 2
CUED SPEECH – CLIP 3
Aids in
developing
spoken
language in
ANY language
Follows
natural mouth
shapes
Cued
Speech
Pros
Not a separate
language
English
grammar and
syntax
Family
must
become
fluent
Cueing at
all times
can be
difficult
Cued
Speech
Cons
Limited
therapist
availability
Limited
educational
placements
Combined Option: Auditory - Oral
 Definition:
 Emphasizes development of speech and language through
maximum use of amplified residual hearing and speech
reading
 Assists in communication, language development, and speech

Beginnings Website: Auditory-Oral
Auditory – Oral: Primary Goals
 Develop internal spoken language and
communication skills through simultaneous listening
and speech-reading
 Support inclusion in school
 Integration into hearing community
A-O: Language Development
 Receptive Language:
 Use of early and consistent training using speechreading and
hearing
 Expressive Language:
 Spoken English
 Written English
A-O: Hearing
 Early and consistent use of personal amplification to
maximize use of residual hearing
 Ongoing auditory management
A-O: Primary Caregiver Responsibilities
 Incorporate strategies learned into daily tasks.
 Use amplification consistently
 Work with teachers and therapists to learn strategies
 Create an optimal oral learning environment
Auditory – Oral Video
AUDITORY – ORAL CLIP 1
AUDITORY – ORAL CLIP 2
AUDITORY – ORAL CLIP 3
Relies on
audition and
visual
Apply
auditory and
cognitive
skills to the
development
of literacy
Can
supplement
information
not available
with audition
A-O
Pros
A new
language does
not have to be
learned by
family
English
grammar and
syntax
maintained
Audition may
not be as heavily
emphasized as
speechreading is
also encouraged
Child may rely
more on visual
information
A-O
Cons
May not be
appropriate for
those with
visual
impairments
Discrepancies
may be observed
between spoken
language and
speechreading
skills
A-V
A-O
Audition Only
Audition +
Vision
Amplification
Amplification
Huge Parental
Requirement
Speechreading
Combined Option: Total Communication
 Definition
 Educational philosophy
 Uses simultaneous oral and manual modes of communication
 Includes an English-based language system, speech,
speechreading, fingerspelling, natural gestures, and residual
hearing

Beginnings Website: Total Communication
Total Communication: Primary Goals
 Goal is to provide input of both auditory and visual
stimulus simultaneously. Both are utilized all the
time for concurrent development.
 Develop internal spoken language and
communication skills through simultaneous use of a
manual English sign system, etc.
 Support integration into both the hearing and the
Deaf communities
TC: Language Development
 Receptive Language:
 Exposure to a combination of sound and sign-based systems in
English-order, speech reading and hearing
 Expressive Language:
 Sign language
 Fingerspelling
 English order
 Spoken English
 Written English
TC: Hearing
 Encourages use of personal amplification to
maximize use of residual hearing
 Requires ongoing audiological management
TC: Primary Caregiver Responsibilities
 All family members MUST learn and use the chosen
sign language system
 Encourage consistent use of personal amplification
 Develop skill by signing consistently with
experienced signers
Total Communication Video
TOTAL COMMUNICATION – CLIP 1
TOTAL COMMUNICATION – CLIP 2
Provides
multiple
avenues for
language
development
Decreases
missed
windows of
opportunity
TC
Pros
Typically
there are
educational
programs
available
English
grammar
and syntax
maintained
Family must
commit and
learn sign
May require
consideration
for educational
placement
TC
Cons
Child may rely
more on one
skill than the
other
It is difficult to
sign and speak
simultaneously
Language Development:
Regardless of Selected Mode
Language development must be fostered early in children
There are “windows of opportunity” which occur, the
mode selected needs to be utilized early on to fully access
those opportunities
“Studies estimate that as much as 90% of what young
children learn is attributable to the reception of incidental
conversation around them.” (Flexer, C. 1999)
Bilingual Considerations
 Options for families:

Use two languages from the start

Use only one language at home, learn a second language at
school
Bilingual Considerations
 Bilingual considerations with hearing loss
 If one language is delayed due to limited auditory access, all
languages will be delayed
 More difficult choices for parents to make
 Children may mix grammar rules
 If the child has the ability to learn one language, then they
have the ability to learn two languages.
What if their ability is dependent upon speech and language
therapy?
 Should they be limited because they have hearing loss?
 Do our expectations shift? Or does our counseling change?

“When the ears do not work properly, the
auditory center of the brain does not get
the stimulation needed to grow and develop.
That is why an undiagnosed hearing loss in
early childhood can permanently affect a
child’s ability to hear and understand subtle
sounds and differences, even if the hearing
loss is treated later (Flexer, C. 1999).”
The Importance of Counseling
 Should provide information
 Balanced and objective knowledge allows families to make
choices that are right for their child and family
 Needs to be done at the very least by the audiologist
and speech-language pathologist
 Need to back up with research
 What do we mean by balanced? Objective?
Factors Influencing
Communication Mode Decision
 Grief cycle
 Location of educational
programs
 Availability of therapists
 Transportation issues
 Other conditions impacting
hearing (e.g., ANSD,
malformations, CND)
 Etiology and/or degree of
hearing loss
 Concomitant factors (e.g.,
syndromes, ototoxic
medications)
 Family support
 Duration of deafness or
hearing loss
Family Checklist
 Recognize




responsibilities
Learn/educate for
informed decisions
Choose a communication
mode
Learn and begin using
communication mode
Communicate with child
using chosen
communication mode
 Include child at all times
 Determine the main
communication model
 Include the entire family
 Research education
approaches, programs,
schools
 Start early, time is
critical
Questions Parents Should Consider
What communication approaches are available?
What features does each approach encompass?
Will training be required to use the approach?
What are specific family responsibilities associated with
each approach?
Do you know what your options are when deciding which
mode of communication?
Questions Parents Should Consider
How well do you feel you understand the options?
Have you been able to experience each in person? Or at
least the ones of interest to you?
Do you understand all test results?
How much time do you have to devote to learning the
methodology of the desired communication option?
Where do you see your child in 10 years?
Considerations from the Professional’s
Perspective
 How do we deal with the social views of each of the
approaches?
 How do we support the parent in their decision?
 Can we support the family if their decision doesn’t mesh
with our own recommendation?
 When do we refer?
 What about when the “system” fails to support the
parent’s decisions?
Commitment
 All modes require a commitment on the part of the
family in order for them to be able to adequately
communicate with their child.


“I want my child to sign. They can teach him that at school. It
isn’t as difficult as some of the other options.”
“I made sure my child received a cochlear implant. Now they
are not talking, and it is your fault. No one told me that they
would need to go to therapy.”
Counseling
 Educate the families so
 How much counseling is
they can make informed
decisions
 How do we check for
understanding?
 Do we have them write
their decision down?
enough?
 Do we have them say it
back over and over
again?
 Do we ask them on a
regular basis if they feel
we are reaching that
goal?

Do all AR Team members
know of the decision made
by the family?

Are we afraid if we do ask
they will say no?
Counseling: An Ongoing Issue
 Includes what normal
speech, language, and
auditory development
entails
 Discussing the
audiological evaluations
 Utilize the “Teaching
Audiogram”
 Importance of early
amplification



Types that may be
recommended for
pediatrics
Verification
Encourage them to seek
out professional guidance
 Don’t just assume that
because a family is using
one mode currently, that
they do not want to
switch for their child
Counseling: An Ongoing Issue
 Model behaviors you
want the parent to do
and have them do it!




Listening check
Looking at the audiogram
for the frequency
information
Looking over the lesson
plan
Verbalizing goals and
skills to work on on a
session by session basis.
 Make the parent the
expert and the advocate





Provide them with
practice
Knowledge of terms
Knowledge of normal
development
Involvement in goal
making
Discussion of rationale –
REGARDLESS of the
goals addressed
Provide Access to Resources
 Encourage families to go visit classrooms where
children are using the different approaches.
 Encourage families to watch the videos and then
identify what they have seen, and whether or not that
matches up with their goals.
 Let families grieve, but don’t forget to inform them of
the importance of early identification and the factors
of success – regardless of the mode chosen.
Educational Settings: Family Questions
What are the school’s expectations for a student with
hearing loss?
What is the school’s philosophy with regards to
auditory development for a child with hearing loss?
If it is a school for the deaf, what opportunities are
there for interaction with hearing peers and/or
mainstream classrooms?
Educational Settings: Family Questions
How much experience does the school have with
educating students with special needs?
What is the school’s policy regarding classroom
observations by parents and other team members?
Is the staff willing to work with professionals from a
different facility?
Educational Placements
Inclusion
 Attends all classes with hearing peers
 Usually in their home school district
 School provides appropriate support services that help
the child succeed in school

Degree of support depends on the child
 Services could include:

Speech and language therapy, assistive listening system, interpreters,
curriculum and test-taking accommodations, resource services,
physical or occupational therapies, and others
 Typically communicate using spoken language, English-
based sign language, or Cued speech.
 Not a common setting for students whose language is
based in ASL
Self-Contained Classroom
 Class is entirely made up of children with hearing
loss
 Taught by a Teacher of the Deaf
 Class is often within a larger public school
 Communicate using either spoken language, Cued
Speech, or sign language
Partially Mainstreamed
 Part of the day is spent in a self-contained class
 Part of the day is spent in an inclusionary setting
Reverse Mainstream
 Class includes a balanced mix of students with and
without hearing loss
 Typically taught by a team of one Teacher of the Deaf
and one general education teacher
School for the Deaf – Day Program
 Entire student body is comprised of children with
hearing losses
 Children are generally bussed from their home district, to
a district which serves a wider regional area
 These programs base their educational approaches on
one of the following:



Auditory/oral
ASL
Total Communication
Residential School
 Student attends and resides at a school for the deaf
 Programs based on the following:
 Auditory-Oral
 ASL
 Total Communication
Mainstream
 Places children with disabilities in regular schools
and classrooms where they follow the mainstream
academic curriculum, without significant problems
or the need for teachers to make curriculum
adaptations.
 Parents and professionals should not confuse
mainstreaming with inclusion, which means a child
is placed in a regular classroom regardless of the
degree of their disability or their ability to access the
regular curriculum.
ASSESSMENT AND THERAPEUTIC APPROACH
Assessment
 Testing
 Standard
 Informal
 Look up information in manuals regarding scoring
and modifications
 Written documentation regarding results and
recommendations
 Supported by research
 Utilizing or not utilizing the audiological treatment
Assessment Objectives
 To assess the child’s articulation skills and speech
intelligibility across varied tasks and situations.
 To assess other aspects of speech including voice,
resonance, and prosody.
 To assess other communication skills including the
child’s auditory comprehension, verbal expression,
and reading and writing skills. Assessment of those
skills will help the clinician develop a patient-specific
plan of treatment.
Assessment Objectives: Continued
 To describe the nature of the child’s speech production
problems and make an estimate of severity.
 To identify potential treatment targets and possible
compensatory communication strategies.
 To make a clinical judgment of prognosis.
 To describe the patient’s strengths and intact skills. This
will help the clinician develop a plan of treatment that
capitalizes on what the patient can do.
Aural Habilitation Services
 Training in Auditory
Perception




Awareness of sound
Identify sounds
Sound discrimination
Attach meaning to sounds
 Using Visual Cues
 Beyond simple lipreading
 Involves all kinds of visual
cues: facial expression,
body language, context,
and environment
 Improving Speech





Production of speech
sounds (isolation, words,
conversation)
Voice quality
Speaking rate
Loudness
Speech rhythms
Aural Habilitation Services
 Managing
Communication




Child understanding
hearing loss
Developing assertiveness
skills
Handling communication
breakdowns
Modifying situations to
make communication
easier
 Managing hearing aids
and assistive listening
devices

Children participate in
hearing aid care and
management as much as
possible (age)
Areas to Assess and Treat
 Audition
 Vocabulary
 Language
 Receptive
 Expressive
 Cognition
 Speech
 Literacy
 Pragmatics
Assessment of patient or self?
 The SLP is obligated to accurately assess and record all of the
current communication skills of the patient.
 Some areas which may be less common, but are still important
include:





AAC
Cued Speech
Native Language (i.e., Spanish)
Sign
Others?
 How to accomplish that? What is ideal?
 Videotape the evaluation if unable to judge certain responses, and consult with
another professional who is able to do so
 Refer to another professional if you are unable to FULLY assess the patient’s
skills
 Using an interpreter (in the room, instead of over the phone)
 Broaden your grab bag of assessment skills

What could that mean?
THERAPEUTIC APPROACHES
VS.
AUDIOLOGICAL TREATMENT
Audiological Treatment or Therapeutic Approach
Cochlear
Implant
AVT
Hearing
Aid
Assistive
Listening
Systems
Visual Phonics
Speechreading
Audiological Treatment
An audiological treatment typically involves some kind
of assistive listening technology. In and of itself, it is
not therapeutic. The treatment will provide a certain
degree of access, which is dependent on the individual,
and the access to sound.
Therapeutic Approach
 Auditory-Verbal Therapy
 Traditional Speech Therapy
 Speechreading to improve literacy skills
 Visual Phonics
 Many, many others!
Therapeutic Approach
A therapeutic approach is a rehabilitation plan which
may or may not utilize the access to sound provided by
the audiological treatment, and provide meaning to
enhance understanding and use of language. A
therapeutic approach will incorporate a
communication mode.
Audiological Treatment
 Fitting and Mapping of Cochlear Implant(s)
 Fitting of Appropriate Amplification
 Hearing Aid(s)
 FM System
Personal
 Soundfield
 Desktop


Noise Maskers (tinnitus)
 Balance
Developing Therapeutic Approach
 Regardless of the mode chosen:
 Primary goal should be to provide an active language enriched
environment for the child, so that receptive and expressive
language is enhanced
 Always need to keep in mind the goal
 How will you present the information?
 What behavior do you want the child or adult to demonstrate?
 How are you influencing their behavior?
 What about the communication mode will influence their
behavior?
Audition Goal
 AB will imitate varying suprasegmental qualities in
phonemes (duration, intensity, and pitch).





AV
AO
TC
Cued Speech
ASL
 Is this an appropriate goal for all modes?
Speech Goal
 Patient will produce early consonants at the
beginning of words.





AV
AO
TC
Cued Speech
ASL
 Is this an appropriate goal for all modes?
Language Goal
 Patient will use plural nouns.
 AV
 AO
 Cued Speech
 Total Communication
 ASL
 In therapy do we always use the communication
mode?
Hierarchy: Vocabulary Goal
 Target Word: Under
 Input


“I Spy”
Comprehension
Following Directions (Put the plate “under” the table)
 Hide and Seek
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Imitation
Action with “under”
 “Simon Says”


Use
“Hide and Seek”
 Where is it?

MODIFYING A THERAPEUTIC APPROACH
When to change an approach?
 Lack of significant
 When one approach may
progress
 Extensive progress
beyond expectations
 Lack of compliance with
recommendations for a
specific approach
 Other concomitant
factors prevent the use of
certain approaches in the
future
not work
 Family dynamics change
 Educational placement
changes
 Hearing levels have
changed, possibly
affecting expectations
References
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American Speech-Language-Hearing Association. (2012).What is language? what is
speech?. Retrieved from
http://www.asha.org/public/speech/development/language_speech.htm
American Speech-Language-Hearing Association. (2012).Social language use
(pragmatics). Retrieved from
http://www.asha.org/public/speech/development/Pragmatics.htm
BEGINNINGS for Parents of Children Who are Deaf or Hard of Hearing, Inc.
(2012). Communication decisions. Retrieved from
http://www.ncbegin.org/index.php?option=com_content&view=article&id=80&Itemid=
130
Cole, E. B., & Flexer, C. (2007). Children with hearing loss: Developing listening and
talking birth to six. San Diego, CA: Plural Publishing, Inc.
First Years. (2009). Listening for environmental sounds. Retrieved from
http://firstyears.org/lib/list-activity.htm
MED-EL. (2012). Communication options & educational placements: A guidebook for
parents. Retrieved from
http://www.medel.com/data/downloads/BRIDGE_US/Resources/Communications_Op
tions.pdf