Auditory Verbal TherapyTraning 2017

In this Presentation, explained about how auditory verbal therapy and training works a cochlear implant children and Key Role of Audiologist.

1. Auditory verbal therapy Amit Kumar Maurya Audiologist and Speech therapist Tree top hospital, Maldives

2. How will I communicate with my child ? How will my child communicate as a normal child ? How will I find a program that will help prepare my child academically, socially verbally ? As we know there are numerous options to improve and rehab for hearing impairment children but AVT is major and crucial strategy.

3. 1n 1977 , A group of clinicians who advocated the auditory approach met in Helen Beebe speech and hearing clinic and in 1978 it was decided to form a special committee called the International committee on auditory verbal communication based on the principle of Acoupedics . The term Auditory-Verbal was suggested by Daniel Ling. AVT is highly specialist early intervention program which equips parents with the skills to maximize their Hearing impairment child’s speech and language development to age appropriate.

4. Basic tenets.. Most children have sufficient residual hearing . If child hears all the sounds through amplification he has the opportunity to develop language in a natural way through auditory modality . All Infants and toddlers learn language the most efficiently through consistent and meaningful interactions in a supportive environment with significant caregivers .

5. Essence of auditory training Auditory sense is the fastest, easiest & most direct means to acquire the spoken language in hearing impairment child. Normal speech & language develop as result of auditory input combined with communicative experience. Auditory channel – self monitoring of speech.

6. Hearing impairment child have a normal central auditory nervous system, the brain’s capacity to process spoken language is assumed to be normal. Thus the critical factor in the acquisition of oral language for children with Hearing impairment is the amount & quality of auditory sounds & experience.

7. 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. 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 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

8. Goals of AVT Better understanding of the spoken language of others . More rapidly development in the use of verbally language . Fluent and better speech clarity . Higher academic achievement . Better social-emotional adjustment through a link with the hearing world.

9. Principles of Auditory-Verbal Therapy Promote early diagnosis of hearing loss in newborns, infants, toddlers, and young children, followed by immediate audio logical management and Auditory-Verbal therapy. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation. Guide and coach parents to help their child to use hearing as the primary sensory modality in developing listening and spoken language . Guide and coach parents to become the primary facilitators of their child's listening and spoken language development through active consistent participation in individualized Auditory-Verbal Therapy.

10. Principles of Auditory-Verbal Therapy Guide and coach parents to create environments that support listening for the acquisition of spoken language throughout the child's daily activities. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child's life. Guide and coach parents to use natural developmental patterns of audition, speech, language, cognition, and communication. Guide and coach parents to help their child self-monitor spoken language through listening. Administer ongoing formal and informal diagnostic assessments to develop individualized Auditory-Verbal treatment plans, to monitor progress and to evaluate the effectiveness of the plans for the child and family. Promote education in regular schools with peers who have typical hearing and with appropriate services from early childhood onwards . An Auditory-Verbal Practice requires all 10 principles.

11. Environment for AVT Method of teaching- one on one, individualized teaching developmental approach (hearing age ) Attitude-emphasis on audition Atmosphere-fullest opportunity to use residual hearing, surrounded by people who expect him to listen and respond and show him how to communicate normally.

12. Acoustic Environment Quiet surroundings are important to ensure that all sounds are heard . Parent/teacher/therapist must stay within “ear shot” that is close to the better ear within 6”-2’ or at least within 5 ’. There should be no squeal from the aid . Hearing aid must be appropriate & well maintained. 6 sound test must be used at the beginning of the session.

13. Beginning therapy Environment is very important. SNR as high as possible, the recommended level is 30dB SNR . Input should be a quiet voice. Since the therapist is near the child’s ear, it will not be very soft. (inverse square Law ) Audiogram/aided audiogram

14. Planning therapy (lesson plan adapted from Shepherd Centre) Concept of Hearing age/implant age. This is recorded along with chronological age . Goals are several- the activity/toy is specified Audition Language/cognition Speech Communication Carry over for parents

15. Purpose of Ling 6 sound test Diagnostic Changes in hearing level To teach children to respond Identify sounds(sound perception ) Distances- 1-3 meters

16. Stages of AVT

17. Awareness or Detection of Sound It is a basic process of determining whether the sound is present or absent . It involve orientation towards other sound in readiness to get more information about it . It helps the child understand which things produce sound which do not, child learns to associate the taught to sound and its source. Awareness of sounds helps the child to remain in contact with the surrounding acoustic world.

18. Discrimination It involves perceiving the difference between sounds-the acoustic qualities, intensities, durations etc., understanding that different objects produce different sounds or that the same source may produce different sounds. Discrimination of same vs. different and generalization of sounds into different categories are complementary abilities.

19. Identification It involves labeling or naming what has been heard by child. The child can indicate the ability to identify a sound by pointing it . Ex /a/;/ i / /p/; /s/

20. Comprehension Understanding of speech Usage of speech in right form can be made by building Language comprehension and expression.

21. Process/Practice Verbal Therapist works one-on-one with parent/caregiver and child. Parents are regarded as the natural language teachers, and primary facilitators, of their child’s spoken language development. Thus parents/caregivers actively participate (80% of each lesson(activity) should be handed over to the parent). The child’s spoken language is learned initially from parents/caregivers in a deeply emotional one-to-one relationship. This relationship cannot be replicated in a teacher-class/therapy room scenario

22. Key to achieving optimal outcomes with Auditory-Verbal Therapy is that learning must be fun. Children learn through play, therefore ‘teaching’ should be through play and child focused activities. Effective Auditory-Verbal Therapy depends on TEAMWORK, with everyone involved acknowledged as an important member of the team. Auditory-Verbal Therapists adhere to the ten Principles of Auditory-Verbal Therapy. It is important to note that six of the ten Principles talk about guiding and coaching parents.

23. AUDITORY-VERBAL TECHNIQUES The following are some of the techniques used in Auditory-Verbal education to enhance a child’s listening, speech and language skill . THE HAND CUE: It 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 ? ACOUSTIC HIGHLIGHTING: It is 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 parents is universal and plays a vital role in helping infants analyses 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 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?

24. 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 vocalizations 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 PAUSING AND WAITING: In this 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 emphasize 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

25. 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 suprasegmental offer good acoustic contrast aiding in speech perception.

26. Role of audiologist The audiologists with the Cochlear Implant Program at The Hospital for Sick Children play an essential role in establishing a child's candidacy for cochlear implantation as well as overseeing the child's audiological care following cochlear implantation. The audiologist typically serves as the child's case manager during the pre assessment period guiding the family through the period of assessment. When the child receives his cochlear implant, the audiologist will then manage his case until the child has reached the age of 18. The audiologist can provide the family with an abundance of information on cochlear implants in children. The audiologist can also provide the family with support throughout this process.

27. Audiological Pre-assessments In order to determine if a child is audiologically a candidate for a cochlear implant, a battery of tests are administered. These tests typically include : Pure tone air and bone conduction testing Electroacoustic analysis of hearing aids Aided soundfield testing Otoacoustic emissions Evoked auditory brainstem response A number of speech perception tests

28. Remember: Audiology is only one part of the assessment process. A multidisciplinary team determines a child's candidacy for a cochlear implant.

29. After the Surgery Following the surgery, the child's cochlear implant is not immediately activated. The external equipment is provided three weeks after the surgery, and the implant is activated one week after that. Equipment Appointment Approximately three weeks after the surgery, the family returns to the hospital and is given the external components of the cochlear implant. The audiologist explains how to operate the device. This allows both the family and the child to become familiar with the manipulation of the equipment and for the child to become accustomed to wearing the equipment for a week before the implant is activated. Older children may not need this step and may instead have a combined appointment to receive the external equipment and activate the implant on the same day.

30. Mapping Approximately four weeks after the surgery and one week after receiving the equipment, the child returns to the hospital for the activation of the implant. The audiologist uses a computer, customized software and a special interface to set appropriate levels of electrical stimulation for each electrode. With the child's equipment attached to the audiologist's computer, T (threshold) and C (comfort) levels are determined. T level is defined as the lowest Current Level to elicit a very soft, but consistent hearing sensation. The C level is defined as the maximum Current Level that does not produce an uncomfortable loudness sensation for the individual. This information is stored in the memory of the speech processor and is called a program or MAP (Nucleus Technical Reference Manual, 1999).

31. When the speech processor is turned on, the child can hear sound. With older children, who are able to report on sound quality, the audiologist can make adjustments to the MAP to optimize sound quality. Because T and C levels may change over time regular Mapping occurs 5-6 times within the initial year of activation. Children are then typically followed every six months for routine Mapping.

32. Evaluations In addition to routine Mapping, all children with cochlear implants are followed at regular intervals to assess speech perception abilities. These assessments include an audiogram in sound field with the cochlear implant as well as the battery of speech perception tests. These evaluations occur annually.