Many readers of Cochlear Implant Online have attended, led, or participated in more Auditory-Verbal Therapy sessions than they can count. For those of you who haven’t, here is a rough sketch of what an AV session might look like. There are many ways to provide high quality services in keeping with the Principles of Auditory Verbal Therapy, and this is just one example of a sixty-minute session (times are approximate and, obviously, will vary from session to session – they are more for organization than exact measures).
:00-:05 Check in with caregiver(s) and child. How was the past week? Did the child do, say, or hear anything new or particularly notable? I also use this time to remind the parent of what the goals were for the past week and to see how home practice went (“Last week, we talked about using the noun modifiers “dirty” and “clean.” How did Susie do with that at home this week?”). This is very important to me, because it reinforces the idea that PARENTS are their children’s primary teachers, and that I will be holding them accountable for working with their child at home. Sure, a parent could just lie and say, “Oh, yeah, it went perfectly,” but a) that’s easy to see through, b) we all know how awful it feels to be put on the spot and be found wanting and have to lie – hopefully that feeling will motivate the parent not to have it happen again and c) the child’s performance in therapy will reflect whether or not skills have been practiced at home during the week. I encourage parents to use their child’s Experience Book to record their observations of their child’s behavior, things the child said, or other milestones during the week to help them remember talking points for therapy.
:05-:10 Equipment and Ling Six Sound Check. This time is used for troubleshooting the child’s HA(s), CI(s), or Baha, to ensure that they have optimal access to sound. A Ling Six Sound Check provides behavioral verification of equipment function. As the child masters the Ling Six Sound Check presented from a close distance and without background noise, distance is increased and background noise (white noise, music, multitalker babble – YouTube is a great source for this from “sound effects” – type videos) to more closely replicate the listening environment of the real world. This is a great time for the therapist to help the parents connect the child’s performance on auditory tasks to his speech and language skills as well as any audiological needs (e.g. if the child is not demonstrating detection of /s/, is it time for a new CI MAP or for a child who is a hearing aid user to consider CI candidacy?).
:10-:50 Let’s play! The majority of the session is spent having fun and working on therapy objectives. The activities and goals vary from child to child, but each session should target goals in the domains of:
Audition: working through Erber’s Hierarchy of auditory skill development, auditory memory, etc. Again, these tasks begin in close, quiet environments, and later are moved to greater distances and greater background noise as the child’s listening skills develop.
Speech: working on the production and articulation of developmentally-appropriate phonemes (speech sounds) and syllable shapes through LISTENING first (no, “Look at my lips,” here, thank you very much!).
Language: working on increasing vocabulary, as well as the linguistic structures (syntax) that the child can understand (receptive language) and use (expressive language).
Communication: working on pragmatic and social language – asking questions, understanding slang and figures of speech, self-advocacy skills, etc.
Cognition: paying attention to the development of the whole child and cognitive/academic skills that are developmentally-appropriate for him.
Some therapists like to plan a separate activity for each of these domains. This usually does not work well for me, as I prefer to plan longer activities that incorporate goals from a variety of areas. It varies between professionals. For me, the “activities” section of the session ALWAYS includes shared reading of a book, and usually includes some sort of craft or take-home activity to reinforce goals throughout the week. There are many different ways to structure this part of the session, but a few things should be consistent between any professionals using an Auditory-Verbal Therapy model:
The goals of each activity should be introduced and explained to the caregiver before the activity begins
The therapist should model the activity for the parent, and then quickly turn the activity over for the caregiver to lead in working with his/her child
Caregivers should be active participants in the session and given opportunities to practice new skills and ask questions
All skills are taught with an emphasis on listening – audition first!
:50-:60 Wrap-up. The therapist discusses with the caregiver (and child, if they’re old enough), the goals and objectives that were targeted during the session, and how the child did. The therapist works with the parent and child to create a new page in the child’s Experience Bookabout what happened during the session, and records goals and activities for the parent and child to work on at home during the time between sessions. Parents (and children) are given time to ask any questions, and the session wraps up.
I love making crafts with children in therapy. It provides a great way to engage children in a variety of pre-academic and fine motor skills while working on objectives in language, listening, and speech. Making something beautiful in therapy gives children a “talking point” to show off to friends and family members throughout the week, encouraging carryover of target structures and social language skills. But as much as I love crafts, there are few things in the world that bother me more than when they’re… NAKED.
What do I mean? Naked crafts are works of art that are so beautiful, so carefully cut, so well thought-out, and completely, utterly, devoid of text and language. I don’t care if that’s the best coffee filter butterfly you’ve ever seen in your life. If it doesn’t come attached to a notecard explainging the speech, language, and listening goals that go along with it, you might as well chalk up the fifteen minutes you spent making it to wasted time. While the child’s parent or caregiver, who was in the session with you, might remember the goals that go along with it for a day or two after therapy (though that’s no guarantee, either), how is big brother at home supposed to know? Or the babysitter? Or his classroom teacher?
Don't leave me hanging! Label those naked crafts.
Here are some suggestions to clothe your crafts with language, and to get more bang for your buck when making things in therapy:
The making of the craft itself should be as clinician-planned yet child-controlled as possible. What do I mean by that? The clinician should “stage” the craft to create maximal opportunities for communication — and teach parents and caregivers to do the same. The glue you need is out of reach? Guess you’ll have to ask for that! The beads are too hard for you to do yourself? It’s self-advocacy time! Don’t know what this piece is called? Well, how do we find out the name for things we don’t know? That’s clinician-planned. And child-controlled? That just means that perfection is NOT our aim here. I like crafts to be as messy and disorganized as the child wishes. Teaching a child that there is a “just right” way to do art goes against the spirit of creativity and takes the joy out of experiential learning.
When I make a book with a family, I write GOALS: on the inside front cover with bullet points of what to remember to highlight when reading the book at home. For more on bookmaking in therapy, see HERE.
Attach a 3″x5″ index card to the back of crafts describing what it is (if not clearly identifiable), and a few sentences about how the child made it, or questions that an observer could ask.
The simplest way to “clothe” a craft is just to label it “Child’s X” (for example, “Jonah’s Snowman”). While it’s not the most detailed explanation, in a pinch, you’ve worked on the child’s name, possessive -’s, and a noun label — not bad for two words!
When a child produces an original work of art, say, “Tell me about it,” and write their narration on the paper, too. For example, if a three-year-old makes what looks to me like a scribble, I could say, in a very nonjudgmental way, “Tell me about it,” and then transcribe his narration, “It’s a tornado. The red paint is going ’round and ’round.” It is important not to interfere with the artist’s interpretation of his work, though I do make changes to what the child’s “raw” narration is to make it grammatically correct as needed.
Have the child rehearse “talking points” on his masterpiece before leaving therapy. Ask, “What did you make?” and help him formulate a socially-appropriate response at whatever his present language level (e.g. for a very young child, the answer to “What did you make?” might just be, “Dog,” while an older child would be expected to say, “I made a brown puppy with felt and glue.”)
If you give a therapist a book… she’s going to want to make one more. Here are some ideas for creating books in therapy to help develop children’s language and pre-literacy skills, as well as to encourage home carry-over of therapy objectives.
Part of every auditory-verbal therapy session for me includes sharing a book with parents and children as a way of promoting literacy and listening and spoken language development. Once the shared reading is complete, there is no better way to continue to learning objectives than to create a book that the family can take home.
WHY is this important?
For many families, the books you create in therapy may be among the few, if any, reading materials they have in their home.
Bookmaking helps parents with low literacy levels have a positive book-sharking experience with their child. If the book and text are made in therapy, at a level that works for the parent and the child, it is more likely to be re-read at home.
If you are working with families who speak a language other than English at home, you might not have the original book in their home language (e.g. does your clinic have Green Eggs and Ham in Urdu?), but, with the help of adult family members and/or an interpreter, you can make a take-home book version in the language that works best for the family.
Books that tie into therapy activities show parents the importance of home practice and set the expectation that goals introduced in the week’s therapy session will be the subject of daily practice at home.
Making a child’s own version of the book you just read is highly motivating, and it takes the experience of shared reading to a more active, hands-on level. You may listen when a book is being read to you, but when you’re making your own book, you’re moving, cutting, gluing, requesting, coloring, and experiencing the book on many different levels.
Bookmaking encourages crucial pre-literacy skills, like understanding reading vocabulary (cover, author, title, page, word, sentence, illustration) and encourages families to read, read, read! For children with hearing loss, who we know are at great risk of poor literacy skills without proper intervention, this cannot be said enough.
Reading a book and then making your own promotes carryover through repetition.
Reading a book and then making your own promotes sustained attention to the same/similar task, an executive function skill that is essential for success in school.
Reading a book and then making your own provides increased exposure to new vocabulary and language structures, increasing the chance that a child will “pick up” on new concepts without having to be explicitly taught.
HOW do you do it?
Pick a book to read in therapy that is developmentally-appropriate for the child and conducive to practicing whatever therapy goal(s) you have in mind.
Make your blank book. You can use printer paper, construction paper, notecards, or anything else you have lying around to recycle. HERE are instructions on how to make a pop-book, a great “magic trick” sure to amaze children (and adults) of all ages. You can also insert your pages into sandwich-sized baggies with the seal on the left, then connect all of the seals with staples to create a “laminated” book to protect pages from little hands. HERE is another website with many child-friendly bookmaking ideas.
Googling “book title” + printables often yields sites that have coloring pages and flannel board printable templates that can be printed and cut out to create the “illustrations” for your book.
Add the child’s picture into the story — increase the personalization and motivation factors for your book.
Make it interesting! Add texture (cotton balls, sandpaper, felt scraps,feathers, etc.), lift-the-flaps, use scissors to take a “bite” out of a page that talks about eating, add pictures from newspapers and magazines, or whatever else you can think of to make the book high-interest as well as high-language!
Use printed illustrations from the book to work on sequencing and auditory memory.
Write the text together, even with very young children, to work on a variety of pre-literacy skills (left to right orientation, grapheme-phoneme connections, basic book handling skills, etc.). This can also help parents who do not read well get a mastery of the text instead of sending them home with something they have no idea how to read. It can also help families who speak a language other than English in the home include words or phrases from their own language in the book.
Use the “inside cover” of your book to write bullet points of goals (with examples) for home carryover.
Underline target structures in the text to remind parents of goals for home practice.
As a founder of CI Online, I receive many e-mails from cochlear implant candidates asking me “Which cochlear implant brand should I choose?” It is the question that I always want to shy away from if I can. For several years until I released the brand comparison chart, I responded to their e-mails by providing them a thesis written by a graduate student who happens to be an Advanced Bionics recipient, presenting a comparison of all three brands. Then, when the thesis became out of date, and I was asked by numerous people to create a brand comparison chart that would be easy to read, I created the brand comparison chart along with several other people so that candidates could simply have an all-in-one place to see the facts.
Because I happen to be a Nucleus cochlear implant recipient, I don’t feel comfortable sharing opinions on the products of other brands specifically because I do not have the personal experience. However, if people do ask me questions about Nucleus cochlear implants, I am more than happy to provide the information because I have personal experiences in utilizing the device and a relationship with the company. When people ask me for opinions about other brands, I always direct them to other recipients of other brands.
So, why am I writing this post? I have seen enough of brand wars on various forums that it has caused some of the most prominent advocates who have years worth of experiences in utilizing cochlear implants and listening and spoken language to step down and leave the forum because they don’t want to be bothered by brand wars. As a result, the forums are left without important voices of people who can provide a wealth of useful information relating to hearing loss in general.
I also saw messages written by recipients of other brands stating that it’s too bad that I am not utilizing other brands and also messages telling other candidates that they’re crazy to chose xyz brand. No one should ever feel uncomfortable about the choices they make.
While I give great credit to Cochlear for providing me access to hearing, I also give tremendous credit to my parents and therapists for teaching me to speak and hear well and also my audiologists for providing me the highest quality of mappings. I score in the 90′s to 100 percent on HINT (Hearing in Noise Test) and love listening to music. What one has to realize that there are so manyvariables for success to hearing well. We can’t give the cochlear implant manufacturers the sole credit for success. We also have to consider the effort we put into rehabilitation, the quality of therapists and audiologists, history of recipients’ hearing loss and also parental involvement.
I will also have to say that I am so grateful that there are four existing cochlear implant brands in the world today because competition is what pushes all manufacturers to continue to improve their devices and make them as superior as they can be. When Med-el created the baby set up for BTE sound processors, Cochlear followed suit. It wasn’t long after Med-el created a slim sound processor that Cochlear came out with a slim sound processor too. A couple years after Cochlear created a waterproof sound processor with a rating of IP57, Advanced Bionics released a waterproof sound processor with a rating of IP68. I am sure that Medel and Cochlear will eventually come out with sound processors that will be swimmable like Advanced Bionics’ Neptune.
ALL manufacturers are researching around the clock to create the highest quality and most-up-to-date technology in order to continue to attract as many new candidates as they can and keep their current recipients for years to come.
The bottom line is that I am so disgusted by brand wars and people claiming this or that brand is the best of all and claiming this or that brand is horrible. Why do we need them in the first place anyway when there is no clear indication of which brand provides the most superior quality of hearing? If one manufacturer was clearly providing all recipients with horrible quality of hearing, that manufacturer would not be making a good business or would be out of business.
Let’s please put the brand wars aside and not spend so much time pushing one particular brand on other candidates. Let’s just be people who happen to hear with cochlear implants and focus on creating awareness of cochlear implants in general and the fact that deaf children can learn to hear and speak today.
Did you know that only 7% of people who are qualified to get cochlear implants are hearing with them today? We need to put effort into letting the general population know about the existence of the technology.
There are many health insurance providers that are still not covering cochlear implants or even bilateral cochlear implants. We need to put effort into advocating for health insurance providers to cover cochlear implants and bilateral implantation.
We have a lot of work to do and spending time pushing candidates to go with a particular brand should not be on the list.
Some important new legislation is coming to the House of the Indiana State Legislature this session: HB 1367. This bill proposes the creation of local, independent, non-biased resource center to provide children identified with hearing loss and their parents with ALL communication options. This is a crucial, positive change for children and families in Indiana, and we need your help to get it passed!
Currently, in Indiana, the responsibility for this initial contact with children with hearing loss resides with the Indiana School for the Deaf, a Bilingual-Bicultural institution that does NOT provide a full spectrum of communication options for children with hearing loss and their parents. How much of a “choice” do parents have when the state is saying, “This [ISD] is what’s free, and if you want anything else (e.g. cued speech, listening and spoken language, Signed Exact English, etc.)… well, you can choose that, but you’re on your own!” Essentially what that means is that, for all but the most well-connected and financially well-off parents, “free choice” is really no choice at all. In addition, HB 1367 proposes some sorely needed accountability measures for ISD, a taxpayer-funded institution that, in 2009, had an abysmal 11.5% ISTEP (state standardized test) English Language Arts and Math pass rate (data HERE) and a 51.7% graduation rate in (data HERE). Taxpayers deserve better, and, more imporantly, parents and children with hearing loss deserve better, too.
Parents know their children best, and deserve access to free, appropriate public services in their communication mode of choice. Ultimately, this bill helps ALL children with hearing loss and their families, regardless of communication mode, by providing non-biased support, access to all options, and standards in place to improve the quality of ISD for parents who choose to send their children to that school.
How can you help? Support HB 1367 by contacting members of the Indiana House Committee on Education. It’s easy to do! Click HERE for a page with their phone numbers and email addresses, as well as a sample letter that you can email or send to them, with space to add your personal story. It will take just a few minutes of your time, and the potential impact for generations of children in Indiana is HUGE.
UPDATE (1/23/2012): Here is a quick and simple solution to contact the members of the House Education Committee. It takes just ONE MINUTE to make a difference in a child’s life. Just copy and paste the following email addresses:
Dear Representative,
I am writing to encourage your SUPPORT for HB 1367.
Indiana’s status quo concerning deaf and hard of hearing education does not work effectively. Parents must navigate multiple state agencies to get information.
{YOU MAY WANT TO ADD YOUR PERSONAL STORY HERE}
Many children fail to receive the appropriate early intervention services they need, thus they enter elementary school lacking the language skills necessary to learn. Placing professionals under one roof will prevent these students from falling through the cracks. The independent center would be unbiased toward any particular mode of communication, and therefore serve all deaf and hard of hearing families regardless of the communication methods chosen.
HB 1367 is the result of an extensive study by the Office of Management and Budget which examined operations at the Indiana School for the Deaf and collected input from numerous stakeholders. The existing law governing the Indiana School for the Deaf has not been updated since the 1990′s. In the last twenty years there have been significant changes in deaf education. Earlier identification and more advanced technologies allow parents a wide variety of communication and education options. Unfortunately, under the current system, Hoosier parents do NOT have equal access to all communication options.
HB 1367 offers the opportunity to align state government to today’s environment. I will be very disappointed if we do not take advantage of this opportunity to move Indiana forward.
Thank you very much for your consideration of HB 1367.
Sincerely,
How important is this? Well, if you take the time to contact the House Committee on Education, we’d like to thank you by having a giveaway of a Cochlear Implant Awareness t-shirt from our shop. Once you’ve contacted the legislators, please leave a comment below this post. Here’s how to enter:
Here’s how to enter:
Contact the House Committee on Education to let them know that you SUPPORT HB 1367.
Visit the SHOP. Check out the Cochlear Implant Awareness t-shirt designs and pick your favorite.
Leave a comment beneath this post letting us know that you contacted the legislators and which CI Awareness design you would like.
You can earn an extra entry by tweeting about SUPPORT HB 1367 and make sure you include @CochlearImplant in your tweet. Please add a comment if you tweeted about the bill.
You can add another entry by blogging about this SUPPORT HB 1367. Please add a comment if you blogged about this bill and link to the blog.
You can earn an extra entry by posting about SUPPORT HB 1367 on Facebook. Make sure you put @Cochlear Implant Online in the status and set the post to be seen by everyone. Please add a comment if you posted on Facbeook.
The winner will be announced by random number generator on Sunday, February 19th at 3PM EST.
Call, send an email, tweet, blog, and do your part. Together, we can make a brighter future for children with hearing loss!
Cochlear Implant Online is not endorsed by Cochlear, Med-El, Advanced Bionics, and AGBell. Articles and comments do not necessarily represent the views of all three companies and AGBell. This website is created by Rachel Chaikof, who is a Cochlear Nucleus bilateral cochlear implant recipient, to create an awareness about cochlear implants and listening and spoken language.
Anatomy of an AVT Session
Let’s focus on giving people access to hearing, not brand wars
