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 Attention Professionals: Considering Auditory-Verbal Therapy certification? Our expert, Linda Daniel, answers pertinent questions on this topic.

Recently, we received several pertinent questions on Auditory Verbal Therapy at HearingExchange. Linda Daniel, a member of our panel of distinguished experts took the time to answer them with great thought and research. Professionals who work with children with cochlear implants will find this article of particular interest.

Q: I am a professional who is considering AVT Certification.  Are there any research articles or data related to spoken language success with pre-lingually, profoundly deaf children who were implanted with a cochlear implant between the ages of 18 months and 2 years?

A: I am not aware of research specifically on children this young, but Ann Geers, Ph.D., at CID in St. Louis is head of a nationwide study to track the speech/language/auditory growth of implanted children. Her results are very exciting, as they document the positive impact of several key factors in the management of children with cochlear implants. The children in this study were implanted by age 5 and had between 4-6 years of implant use.

The study entitled, "EFFECTS OF EDUCATIONAL CHOICES ON THE SPEECH AND LANGUAGE DEVELOPMENT OF CHILDREN IMPLANTED BEFORE AGE 5" was designed to measure speech perception, speech production, language and reading. Communication method, class placement and therapy were evaluated as they effected children's speech perception, speech production, language and reading. The data were corrected for the influence of particular patient characteristics. The conclusions that are supported by the preliminary data analysis are:

(1)The child characteristics associated with better performance on the outcome measures were onset of deafness after birth, early implantation and good learning ability.

(2) The important implant characteristics  included a full electrode insertion and a well-fitted map that allowed a full range of perceived loudness as stimulus intensity increased.

(3) When the factors of 1 &2 were controlled for, the primary rehabilitative factor associated with performance outcome was educational emphasis on hearing and speaking communication (auditory-verbal, oral-aural, etc.) rather than sign language. 

(4) In addition, children who were most successful with their implant were placed in mainstream classes with relatively little sign language use by the time they reached 8 or 9 years old.

Q: What percentage of these children develop normal language with the AVT approach? 

A: No data have addressed this specific question. Typically the factors Geers mentions as having positive impact on the child's auditory-verbal development are good indicators of the children who will achieve the highest levels of speech/language/audition. These include early intervention, a verbal communication program that emphasizes hearing and speaking, parents who assume a primary role in their child's therapy and educational program, social and educational mainstreaming, etc. Current studies are documenting the positive effects of the principles of the AV philosophy that have been in used for nearly 50 years. They are listed below:

Principles of Auditory-Verbal Management

Adapted for this article by L. Daniel. Obtained from: Pollack, D. , 1985, Educational Audiology for the Limited Hearing Infant and Preschooler, Chas. C. Thomas Publ.

1. Promoting spoken language as the child's means of communicating. We use speech to teach speech: the use of formal visual communications such as cued speech or sign language is not part of auditory-verbal communication.

2. Supporting early diagnosis of the hearing impairment and fitting of hearing technology shortly after diagnosis including hearing aids, a frequency transposer aid, an FM system, or a cochlear implant. This capitalizes on the child's ability to learn hearing and speech more quickly in the early years. Little if any time is lost in providing the child with auditory input.  Selection of hearing technology is done on an individualized basis to maximize each child's ability to hear conversational speech and learn to talk. Vigorous medical and audiologic management is essential to optimal hearing.

3. Developing a parent-therapist partnership to teach parents to be their child's advocate and primary model for verbal learning: this capitalizes on the natural role of communication in the parent-child bond. The parent is involved in all therapy sessions and learns to teach the child to talk during routine living experiences within the home and community.   The parent, not a therapist or teacher, is the child's primary source of language learning. Parents learn to use continuous opportunities offered by a child's life to establish the habits of listening and speaking.

4. Individualizing therapy with the child and the parent(s).  Children are seen individually in therapy with their caregivers to receive a customized treatment plan. The AV therapist's role is to educate, empower, guide, counsel and support parents so that listening becomes a way of life for the child. The needs of each child and family are unique and require the therapist's undivided attention and expertise.

5. Developing speech through the child's hearing sense.  The child learns to hear his own voice and imitate the speech of others much like young children with normal hearing. First, vocal play develops, then babbling and jargon, followed by words and sentences.  Lip-reading is not formally taught: most children in AV programs use visual information to supplement what they hear and become excellent lip-readers because they become competent at using the English language.

6. Maintaining a normal living and learning environment. The family's routines, values, recreational activities, hopes and dreams are applied to the child with hearing impairment. Parents are encouraged to apply the same expectations for their child with hearing loss as for their other children. The child's life is transformed into an auditory learning environment so that sound becomes a part of the child's personality and memory for all experiences.

7. Stimulating/guiding the child through normal stages of development for hearing, speech and language. AV management teaches the child to attend to sound. This leads to the unfolding of the brain processes for hearing, active and passive listening and verbal communication. As the child's discrimination and memory for sound increase, so does his vocabulary and use of phrases and sentences. Parents use the events of daily life to advance the child's auditory and verbal skills. The child is allowed the first few years of listening to lay an auditory foundation for communication.

8. Ongoing evaluation and monitoring of the child's needs. A child's need for various technologies and therapies change over time. Therapy is viewed as a diagnostic process: information learned about the child is shared with the parents and the child's program is modified as needed.

9. Coaching the child for independent functioning for social and educational mainstreaming.  With hearing children as friends and attendance at preschool and school with hearing children, the child is immersed in role models for verbal communication and the expectations of the community.

The results for children implanted even earlier will be even more exciting. In my practice, some children implanted early and whose families have committed themselves to the Auditory-Verbal philosophy/approach from the beginning are fully mainstreamed in regular schools from preschool forward. Many learn to hear and talk on the telephone, can understand television, and function with only mild limitations in the hearing/speaking world. Typically, the younger the child is at implantation, the easier it is for them to develop sophisticated hearing and speaking skills and the more quickly they develop natural-sounding, intelligible speech.

Q: What if a child doesn't develop normal spoken language by school age, then where does the child go to school? 

A: Often the children do not have "normal" language by school age but have enough language to participate successfully in the mainstream with appropriate home programming and school support services. Parents must play a very active role in their child's education. Amanda Mangiardi's booklet entitled "A Child with Hearing Loss in Your Classroom? Don't Panic!" (AG Bell, Publ.) offers a great format for parents to use. A recent article in AG Bell VOICES, "Making the Grade: Cochlear Implant Rehabilitation in Public Schools", provides excellent guidelines for support services in the public school. The authors describe a progressive school district in Maryland that has made a commitment to foster the auditory-verbal communication skills of children with hearing impairment.

Q: If a child is not ready to be mainstreamed would an oral school be considered?

A: This is completely evaluated on a case by case basis. The family involvement is a key factor as is the quality of each program and it's view of the child's education. Some children to go to oral schools for a number of years, others mainstream.

Q: Are AVT and AVI against oral schools and if so, why?

A: The goal of AV training is to maximize each child's auditory-verbal communication and competency in the social and educational mainstream. We do whatever we can to accomplish this goal: some children and their situations allow for more mainstreaming than others. The AV philosophy promotes mainstreaming whenever possible so the children have the opportunity to interact verbally with children who have normal speech/language interactions. The mainstream also allows the child access to the same curriculum their hearing peers use.

© Copyright Linda Daniel, 2001.

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