Facilitating spoken
language development in
the regular classroom
September 28th & 29th
Winnipeg, MB
Petra Smith M.Sc. Aud (C)
Audiologist/Certified Auditory Verbal Therapist
AV PRINCIPLES AND
THE AV SESSION
How the auditory verbal therapist
works with the children, their
families and other professionals
Auditory Verbal Services in
Manitoba:
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Located at the Central Speech & Hearing Clinic
Audiology Services & Family Centered Intervention
AVT for families with children using hearing aids or
cochlear implants
Cochlear Implant Candidacy Evaluations & Device
Programming
Aural rehabilitation for older students & adults with
cochlear implants
Professional Development & Mentoring
Education
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Auditory Verbal Therapy (AVT)
Who can deliver AVT?
Auditory Verbal Therapists are practising
professionals in Speech & language Therapy,
Audiology, or Education of the Deaf who
have received specialised training
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Auditory Verbal Therapist –
experience & training
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SPEECH LANGUAGE PATHOLOGIST
EDUCATOR of children who are deaf or hard of hearing
AUDIOLOGIST
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Certified by A G Bell:
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Listening and Spoken Language Specialist
www.agbellacademy.org
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Standardized Curriculum for
Trainee Therapists:
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History & Philosophy
Hearing & Audiology
Spoken Language Development
Parent Guidance
Cochlear Implants
Education in the mainstream
Auditory Verbal Practice
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Auditory Verbal Therapy (AVT)
What is AVT?
An individualised, auditory, developmental
programme, implemented by the child’s family in
close collaboration with a therapist, with the goal
of achieving age appropriate spoken language
ability, and full social participation throughout
childhood and beyond.
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Auditory Verbal Therapy..
…..is part of the Auditory Verbal Approach
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
THE AUDITORY VERBAL APPROACH
“The auditory verbal approach is a mindset of expectations”
(Pam Talbot, AVT)
 Hearing
and audiology
Parental involvement
 Spoken Language Development
 Education
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Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Ten Principles of AVT
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Adapted from the principles developed by
Doreen Pollack, 1970
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Adapted by the A G Bell Academy for
Listening & Spoken Language, 2006
www.agbellacademy.org
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle #1
“ Promote early diagnosis of hearing
loss in newborns, infants, toddlers
and children, followed by
immediate audiologic management
and auditory verbal therapy”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Hearing vs Listening
(Flexer, 2005)
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Hearing is acoustic access to the brain. It
includes improving the signal to noise ratio by
managing the environment and utilizing
hearing technology.
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Listening is attending to acoustic events with
intentionality.
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Hearing loss
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Hearing loss is not about the ears; it is about
the brain.
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Hearing aids, FM systems and cochlear
implants are not about the ears; they are
about the brain
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(Flexer, 2005)
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Functional impact of hearing loss:
distance hearing
Flexer 1999
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Functional impact of hearing loss:
incidental learning
Flexer 1999
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Hearing loss = auditory
deprivation
If caregivers want their child/ren to develop
spoken language, early identification and
optimal amplification =
“ a neurodevelopmental emergency”
(Flexer, 2005)
..due to the impact of auditory deprivation
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Neuroplasticity
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Greatest in the first three and a half years
The younger the infant, the greater the
neuroplasticity
Rapid infant brain growth requires prompt
intervention
No sound = reorganization of brain to receive
other sensory information
No sound reduces auditory neural capacity
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Typical Language
Development Means..
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Optimal use of the brain for skills
human beings are pre-disposed to
acquire – ie: spoken language
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Best opportunity to achieve success
in areas which must be taught – ie:
reading
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Implications for Intervention
Developmental approach
…instead of….
Remedial approach
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
GOAL:
Universal Newborn Hearing
Screening
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Goal – at identification
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Support families in making their decisions
about:
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Language of choice
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Communication approaches
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Communication Options:
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Manual
Oral
Sign
Language
(ASL)
Spoken
Language
(English/French etc)
---------------------------------------------------------------------
Bi-bi
Auditory Verbal
Signed Exact English
Aural-oral
Total Communication
Cued Speech
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV therapist offers
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Time to reflect, question, feel, grieve
Information – re:
Technology
Hearing
Spoken language development
General developmental issues
Action – what to do!
Contact with other families
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 2
“ Recommend immediate
assessment and use of
appropriate, state of the art
hearing technology to obtain
maximum benefits of auditory
stimulation”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
A good acoustic signal is needed
for auditory stimulation
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Amplification – improves quantity
and quality of acoustic signal
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Good audiological support
Early identification of
hearing loss
Accurate diagnosis
Optimal amplification
Early intervention
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Early amplification
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Research shows that children who are
identified with a hearing loss by six months of
age, provided with optimal amplification and
family based intervention, have the potential
of entering kindergarten on a par with hearing
peers.
Ref: Yoshinaga Itano
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Amplification
Hearing aids
Cochlear implants
All require optimal fitting to allow access to
spoken language.
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Advanced Bionics 90k Implant
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Speech Processors from
Advanced Bionics
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Wireless FM with iConnect
earhook
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Freedom Speech Processors from
Cochlear Corporation
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
MicroLink Freedom for the
BTE
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Seamlessly integrated into the BTE case
FM receiver can be left in place all the time
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 3
“ Guide & coach parents to help
their child use hearing as the
primary sense modality in
developing spoken language
without the use of sign language or
emphasis on lipreading”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
A person who really listens
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Is motivated
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Has time and opportunity
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Is attentive
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Auditory Skills Development
The auditory verbal approach seeks to
maximize the use of audition in the
development of spoken language.
Levels of auditory skills:
detection -> discrimination -> COMPREHENSION
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Goals – infants & toddlers
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Supporting families in hearing aid fitting
and evaluation by:
Facilitating use of amplification all
waking hours
Monitoring prelinguistic vocalizations
Collaborating with audiologists comparing hearing tests with functional
measures of benefit
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Assess, monitor & facilitate:
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Auditory development:
awareness of sound
attaching meaning to sound
vocalizations
Eye gaze & joint attention
Development of natural gesture
Play
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 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 AV therapy.”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Parental Involvement
Parents are the child’s:
Primary language models
 First teacher
 Playmate
 Advocate
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Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Play as the engine of
language development
“In the early stages it is the playful
behaviours of the adult and the child that
generate the language. By the time they are
into fully fledged socio dramatic play, the
language shapes reality.
“I ‘m ‘tending this is a snake. By the way it is
a snake”
From Play by Catherine Garvey
Fontana/Open Books 1977
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Why individualized therapy?
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Why do children need language?
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CONVERSATION
Social interaction
Problem solving and thinking
Negotiation and sharing
Story telling
Joint imaginary play
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
A CONVERSATION IS..
…A SERIES OF TURNS
…A SHARED ACTIVITY
…GOVERNED BY RULES WHICH ARE LEARNED IN
INFANCY
…EASIER FOR ADULTS THAN FOR CHILDREN
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
CONVERSATION
“Informal exchange of ideas by
spoken words”
Concise Oxford Dictionary 1982
so…one of our aims is:
..give the words to the child..
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
How hard can it be?
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
A bad conversation..
Think of someone you would gladly
cross the street to avoid, rather than
have a conversation with them.
Why would you rather avoid them?
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
A good conversation…
Now think of someone you enjoy having a
conversation with. What do they do that
makes it so worthwhile?
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
The rules of conversation:
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Must initiate or respond when others initiate
Take turn at appropriate time
Give partner time to take a turn
Attend to speaker
Keep conversation going
Stay on topic
Send clear messages
Clear up misunderstandings
Start a new topic when needed
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
The underpinning to conversation is…
…equally shared participation
Like a game of table
tennis….
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
But…
What if one of the participants isn’t very
competent?
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Conversations
What can go wrong?
The rules of conversation are not observed
due to:
DELAYED development
DISORDERED development
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
If left unattended..can result in
the child…
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Not seeing the potential in toys
Not knowing how a sequence develops
Not understanding the joint goal
Finding sharing very hard
Experiencing more frustrations than
enjoyable challenges
Other people don’t seem like play
partners
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
The usual solutions adopted by adults
can feel very unsatisfactory, such as:
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Doing all the talking
Asking a lot of questions and then answering
them
Constantly offering new things to try and
catch the child’s attention
Non-verbal games
Trying to direct the child’s behaviour
Describing and explaining the child
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
To avoid this families need:
•
Information – sensitive to adult learning
styles, literacy levels etc
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Demonstration – observation and
participation
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Experience – practice and feedback
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Take home messages for families:
Parents as play partners, and language
models
Equal participation in conversation, even
for the least skilled person
Viewing the child from the first session as a
person with ideas and thoughts to
express
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Dr Edward Zigler
(Founder of Head Start)
“ Literacy begins with thousands of loving
interactions with parents after an infant
is born…it begins with sitting on a safe
lap, hearing a familiar bedtime story”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 5
“ Guide and coach parents to create
environments that support listening
for the acquisition of spoken
language throughout the child’s
daily activities.”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Listening, language and
thinking
“ Listening is not a mechanical decoding
skill. It is a complex and problematic
aspect of communication and
thinking….listening is thinking; as we
listen we make all kinds of judgements
and choices” (Haynes 2002).
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
So…..
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The children need access to spoken
language
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Enhancing listening
Can modify:
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environment
acoustic signal
interactions
…..more later….
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV principle # 6
“ Guide & coach parents to help
their child integrate listening and
spoken language into all aspects
of the child’s life”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Everyday life – more resources for
families ………
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Strategies for parents to try:
Adopt role as play partner – Having fun!
Equal participation in conversation.
Having fun listening.
Encouraging turn taking.
Engaging in joint attention.
Commenting & expanding
Interpreting child’s communicative
attempts.
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 7
“ Guide and coach parents to use
natural developmental patterns of
audition, speech, language,
cognition and communication”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 8
“ Guide & coach parents to help
their child self-monitor spoken
language through listening”
..auditory feedback loop
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AUDITION & SPEECH ACOUSTICS
Factors affecting speech intelligibility:
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timing of onset of deafness
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nature & extent of hearing loss
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type & appropriateness of amplification
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speech perception
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communication option chosen for the individual child
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other challenges
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Early identification allows..
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Less delay
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More natural development
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More acceptable speech patterns
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Better literacy outcomes
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 9
“ Administer ongoing formal and
informal diagnostic assessments
to develop individualized AV
treatment plans, to monitor
progress and to evaluate the
effectiveness of the plans for the
families”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Spoken Language
Follow developmental sequence in:
 RECEPTIVE LANGUAGE
 EXPRESSIVE LANGUAGE
 PRAGMATICS
 PHONOLOGY
 COGNITION
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Therapist will:
Follow typical developmental milestones
 Use criterion referenced and
standardized tests developed for
typically hearing children
 apply the formula for calculating
‘hearing age’
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Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AV Principle # 10
“ Promote education in regular
classrooms with typical hearing
peers and with appropriate support
services from early childhood
onwards”
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AVT in school – AV goals & the
curriculum
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IEP Team involvement
Collaboration with classroom teachers,
resource teachers, SLPs etc
Training for EAs
Ongoing therapy sessions as needed
Regular assessment & monitoring
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Outcomes of the Auditory
Verbal Approach
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Early intervention outcomes
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Emerging data are showing that over 90% of
children born with a profound hearing loss who
obtain a cochlear implant before 18 months, attain
intelligible speech.
This outcome is based on consistent use of the
device and placement in regular classrooms.
Extra auditory stimulation is also necessary.
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Geers et al (2003)
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N – 181
Children received implant before 5 years
4 year longitudinal study
Looked at variables influencing outcomes
(eg: gender; age at onset; etiology; age at implant; residual hearing;
educational placement; type of intervention; commuication mode)
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Outcomes measured by assessments normed on
hearing population (speech perception; speech production;
spoken language; total language; reading)
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Geers et al – Findings:
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All children showed strong language and literacy
skills
>50% achieved grade level reading skills by grades
2 or 3
>50% fully mainstreamed
Girls performed better on language measures
Educational placement - important predictor
Earlier implantation (<5) – better outcomes
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Geers et al – Findings:
“ The dominant educational factor associated
with high performance levels was the extent
to which a child’s classroom communication
mode emphasized speech and auditory skills
development” (Moog & Geers 2003 p124s)
REF: Ear & Hearing Vol. 24 # 1 Special Supplement Eds: Geers, A E &
Iler Kirk, K
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
AVT ..a therapy session..
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60 to 90 minutes long – every week
Listening games
 Songs and books – with actions and
props
 Crafts, cooking and painting
 Pretend play
 LOTS of conversation……
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Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Therapy session framework
MOTIVATION
GOALS
CONTENT
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Organizing the session
Planning highlights specific target areas & skills
in the therapist’s mind. 3 common strategies:
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THEME based planning – activities with a
common topic (less structure)
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SKILL based planning (more structured)
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ACTIVITY based planning (daily routines)
Petra Smith M.Sc. Aud (C) Sept 28/29 2009
Petra Smith M.Sc. Aud (C) Sept 28/29 2009