Optimizing spoken language development in infants and young


Simultaneous bilateral cochlear implantation and auditory-verbal therapy:

Optimizing spoken language development in infants and young children.

Lisa Katz, M.H.Sc., S-LP (C), Reg. CASLPO, LSLS Cert AVT®

Maria Emilia De Melo, M.Fga., S-LP, Aud (C), Reg. CASLPO, LSLS Cert AVT®

Toronto Public Health/ Toronto Preschool Speech & Language Services/ Infant Hearing Program, Toronto, Canada

Simultaneous bilateral cochlear implants are now routinely provided to young children with severe to profound hearing loss in Toronto, Canada. Bilateral stimulation enables these children to establish binaural processing and hear with greater ease (Papsin and Gordon, 2008). When this technology is coupled with early identification and auditory-verbal intervention, children have optimal chances of benefiting from the sensitive periods of neurological and linguistic development. As a result, they can achieve their maximum potential in the development of spoken language.

Auditory-Verbal Therapy

Auditory-Verbal Therapy (AVT) is an individualized therapy program that facilitates optimal acquisition of spoken language through listening by infants and young children who are deaf or hard of hearing. AVT promotes early diagnosis, one-on-one therapy, and state-of-the-art audiologic management and hearing technology. Parents and caregivers actively participate in therapy. Through guidance, coaching, and demonstration, parents become the primary facilitators of their child’s spoken language development. AVT must be conducted in adherence with all ten principles of the approach

(definition adopted by the AG Bell Academy for Listening and Spoken Language®, July 26,

2007 http://www.agbellacademy.org/AuditoryVerbalTherapy.htm).

Case Study

The Toronto Infant Hearing Program (IHP) provides the opportunity for all newborn babies to have their hearing screened. If the infant is diagnosed with a permanent hearing loss, various services are provided to the family, for example, audiologic management and family support.

The family support worker (FSW) makes referrals to services for growth and development and communication supports and services. Depending on the family’s needs and expectations for their child, the FSW refers the family to either a visually based or an auditory based approach.

The following case study serves as an illustration of what nowadays is considered to be a fairly common profile of a child enrolled in the

Toronto IHP. That is, the child presents with a congenital severe to profound hearing loss, the hearing loss is identified through newborn hearing screening and the diagnosis is confirmed shortly after birth. In addition, the child’s first pair of hearing aids is obtained shortly after diagnosis, therapy begins early and the child receives simultaneous bilateral cochlear implants by twelve months of age.

The child described below was enrolled in auditory-verbal therapy and received services from a speech-language pathologist who is also Listening and Spoken Language Specialist (LSLS) certified auditory-verbal therapist and has extensive experience working with infants and children who are deaf or hard of hearing. As a result of her progress, she has recently been discharged from receiving weekly therapy services and is currently being monitored.

Current Skills


• Performs auditory-cognitive tasks

• Understands and uses early spatial, quantity, and quality concepts (e.g., up, one, big)


• Takes turns appropriately

• Has an age appropriate attention span

• Exhibits good eye contact


• Understands primary speaker in the presence of background noise or a competing message

• Identifies hummed songs

• Overhears conversation

• Localizes and identifies sounds at all angles and from a distance

• Uses appropriate suprasegmental features of speech (e.g., exclamation, question, and negation)

• Sings known songs and recites nursery rhymes

• Produces age appropriate speech sounds. Produces word endings spontaneously (e. g., tru


, cry


, and we



• Spontaneously produces fiveword approximations with different semantic relations

(e.g., “Do you want some milk?”)

• Answers and asks age appropriate “Wh-” questions

(e.g., What, Where, and Who).

• Follows two-step related commands

Cognition Communication Behaviour

• Complies for the duration of the therapy session (1 hour)

Principles of Practice*

1. Promote early diagnosis of hearing loss in newborns, infants, toddlers and children, followed by immediate audiologic management and Auditory-Verbal Therapy.

2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation.

3. Guide and coach parents


to help their child use hearing as the primary sensory modality in developing spoken language without the use of sign language or emphasis on lip reading.

4. 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.

5. Guide and coach parents to create environments that support listening for the acquisition of spoken language throughout the child’s daily activities.

6. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child’s life.

7. Guide and coach parents to use natural developmental patterns of audition, speech, language, cognition and communication.

8. Guide and coach parents to help their child self monitor spoken language through listening.

9. 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.

10. Promote education in regular classrooms with typical hearing peers and with appropriate support services from early childhood onwards.

(Adapted from the principles originally developed by Doreen Pollack, 1970)


The term “parents” also includes grandparents, relatives, guardians, and any caregivers that interact with the child.

*Adapted from the principles of Auditory-verbal Practice. © 2006 A.G. Bell Academy for Listening and Spoken Language®.

Factors Impacting Performance

A child’s auditory-verbal progress depends upon a number of variables, such as:

Timing of hearing impairment

Age at diagnosis

Cause, type, and degree of hearing impairment

Use of hearing aids prior to cochlear implantation

Chronological age at cochlear implantation

Effectiveness of the hearing technology

Effectiveness of audiological management

Auditory potential of the child

Skills and knowledge of the therapist

Skills of the parents or caregivers

Child’s learning style and intelligence

Emotional state of the family

Level of participation of the family

Background Information

Chronological age

Gestational age

Age at diagnosis



Age received hearing aids

Age started Auditory-Verbal Therapy

Age at implantation

Hearing technology c

c c c c c c

2 years

40 weeks

2 months


Bilateral profound sensorineural

2 months

4 months

10 months

Bilateral Nucleus Freedom cochlear implants simultaneously implanted


One year post activation of the cochlear implants

Jerry Northern and Marion Downs, From Hearing in Children, (5th Edition, pg. 18),

Lippincott Williams and Wilkins, Baltimore, MD, 2002.

Test Results

PLS- 4 Test Scores
























AC Score




















EC Score











































– January 6, 2009


– June 10, 2008


– October 2, 2007

Preschool Language Scale-4 (PLS-4)

The PLS-4 is used to assess receptive and expressive language skills in infants and young children. There are two subscales,

Auditory Comprehension (AC) and Expressive

Communication (EC). The PLS-4 also assesses behaviours considered to be language precursors.

Parent Perspectives

1. About AVT

According to parents interviewed:

“AVT has not only provided me with ongoing guidance regarding the management of my child’s hearing loss, but also with support in all areas of my child’s development.”

“My therapist has empowered me to advocate for my child and to feel positive about her future.”

“AVT makes sense as it follows the typical sequence of child development and is carried out in daily situations.”

“AVT has taught me all that I know, from the basics about hearing technology and selecting appropriate toys to achieving my child’s communication potential.”

“AVT has provided me with support and guidance regarding my concerns.”

2. Challenges Faced

According to parents interviewed:

“The biggest challenge is to educate people about deafness and to enable them to understand the fact that our kids have the potential to learn to listen and talk.”

“Finding a childcare that does not underestimate my child’s potential.”

“Keeping the cochlear implants on was my biggest challenge. As a baby, she would take them off and put them in her mouth. Now we are over that and the problem is different…..We both get frustrated when we have to take them off to swim, bath or play on the slide.”

“I worry about acceptance when he is older. Others accepting him and he being comfortable with his difference.”


With the advent of newborn hearing screening and state-of-the-art hearing technology, children who are deaf or hard of hearing and their families can benefit from auditory-verbal therapy more than ever. Early diagnosis and intervention enable children to access speech and environmental sounds, helping to stimulate central auditory pathways which are highly plastic in the first years of life. As illustrated in the case study, auditory-verbal therapy combined with early simultaneous bilateral cochlear implantation has facilitated the closure of the gap between the child’s hearing age and chronological age.


Toronto Infant Hearing Program

201-225 Duncan Mill Road

Toronto, Ontario, Canada

M3B 3K9


(416) 338-8255


(416) 338-8511


(416) 338-0025 www.tpsls.on.ca

[email protected]

Infant Hearing Program

Speech & Language Program

Blind–Low Vision

Early Intervention Program

The authors wish to recognize the support of the Ministry of Children and Youth Services of Ontario and the support of the team members of the Toronto

Public Health: screeners, support assistants, data entry professionals, program evaluator, and managers. Thank you for your contribution and support.

We dedicate this presentation to the families and their children and to the early childhood professionals in Toronto and the Greater Toronto Area.

Funded by Toronto Public Health, City of Toronto


Presentation Poster

Client Contact:

Lisa Katz (647.212.8710)

Communication Coord:


Hassan Akbar

Pauline Jackson

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Revision meeting date: