Auditory verbal therapy

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) arc 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.
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.
Principles ofAuditory-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 oftheir
child's listening and spoken language development through active
consistent participation in individualized Auditory-verbal Therapy.
• Guide and coach parents to create environments that support listening for the
acquisition ofspoken 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 1O principles.
ENVIRONMENT FOR AVT
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.
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.
• Audiogram/aided audiogram
Planning therapy

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

• Awareness Or Detection of Sound

• Discrimination
• Identification
• Comprehension
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.
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.
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/
Comprehension

• Understanding Of speech
• Usage of speech in right form can be made by building Language
comprehension and expression.
Process/Practice
• Verbal Therapist works one-on-one with parents /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
• 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.
 AUDITORY-VERBAL TECHNIQUES
• 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:
• ACOUSTIC HIGHLIGHTING: It is speech used by parents/caregivers in talking
with young children to make speech more audible to help them in learning
language.
• 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.
• 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.
• 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..
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.
Audiological Pre-assessments
In order to determine if a child is audiologically a candidate fora
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 sound field testing
• Otoacoustic emissions
• Evoked auditory brainstem response
• A number of speech perception tests Remember:
 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.
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).
• 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.
Benefits of mapping

• Improved speech understanding and sound clarity

• Enhanced ability to localize sound sources
• Increased listening comfort and reduced distortion
• Overall better quality of life and communication for the
cochlear implant recipient
Neural response telemetry
• Electrically evoked compound action potentials (ECAPs also known
as neural response telemetry [NRT]) facilitate intraoperative
determination of device functionality and optimal electrode
placement.
• The ECAP wave is typically formed by a negative peak (N1) followed
by a positive peak (P2).
• The response amplitude (measured between N1 and P2) varies with
increasing stimulus intensity and is measured in microvolts.
The applications of NRT
• to confirm correct implant function and electrode array insertion
by obtaining the ECAPs
• to track implant function over time
• to assist the fitting process by using the ECAP thresholds as
estimation of audible stimulus levels and loudness.
 The recent
Advancements In
Hearing aids
Technology
• Hearing aids are an incredible innovation to help those who
experience hearing loss improve their hearing.
• They were originally invented in the late 19th century, but have
undergone many significant developments since then, taking
advantage of the latest in audio technology to create devices that are
extremely valuable to those who have hearing loss.
• The advancements in technology have made hearing aids more
automatic and added many interesting features that have enabled
individuals with hearing impairment to communicate with their
surroundings via flashing lights or vibrating devices.
• Recently, hearing aids have also been coupled with a smoke detector
and sounds of doorbell or alarm.
Bluetooth and Smartphone Connectivity
• With smartphones becoming such an essential part of everyday life, it
was inevitable that hearing aid technology would evolve to work with
smartphones to enhance the support and features they provide.
• Bluetooth-compatible hearing aids allow the wearer to connect their
hearing aids directly to devices like their smartphones, TVs and
computers to amplify the sounds directly – working in a similar
fashion to earphones
Artificial intelligence and Machine
Learning
• Artificial intelligence and Machine Learning
• Artificial intelligence continues to revolutionize technology and is
being used to develop powerful features in hearing aids. AI can help
improve the user experience by automatically adjusting according to
different environments and conditions, while machine learning can
provide a more tailored experience for the individual – recognizing
different preferences and adapting accordingly.
Longer Battery Life and Faster
Charging
• Hearing aids are worn daily, but their limited battery life can be an
issue for wearers.
• Most new hearing aid designs come with rechargeable batteries,
allowing them to be charged overnight (like wireless earphones) and
making them a much more convenient solution compared to
traditional hearing aids.
Adapted Designs to Suit Different
Aspects of Life
• No two hearing aid wearers are the same. Lifestyle choices and
personal tastes and preferences can determine the type of hearing
aid an individual prefers to wear.
• Today, there are multiple styles of hearing aids to suit different
needs, including those designed for active lifestyles, discreet styles
and even waterproof styles.
Features to Ease Tinnitus
Symptoms
• Tinnitus can be debilitating, but the latest hearing technology can
help ease tinnitus symptoms to provide relief for those who
experience tinnitus symptoms.
• This can include the use of masking noises such as white noise,
controlled by a compatible app that a user can activate when needed.
Two-Way Audio for Easier Calls
• Many of the advances in hearing technology replicate the features of
earbuds and other listening devices.
• More and more hearing aid models are being designed with features
like two-way calling, which can allow wearers to make phone calls
without the need for an additional microphone.
Amplification of specific bands
• All hearing aids process sound, i.e., after receiving the sound, the
hearing aids section it into bands of sounds (called channels) and
digitize before amplification.
• An advanced hearing aid supports better flexibility to amplify the
band of sounds according to one’s needs.
 reference
• Kulkarni K and Hartley DEH. Recent advances in hearing restoration. J R
Soc Med. 2008;101:116–24.
• Shinners MJ, Hilton CW, Levine SC. Implantable hearing devices. Curr
Opin Otolaryngol Head Neck Surg. 2008:16:416–19.
• Chang P. Implantable hearing devices: beyond hearing aids. Aust Fam
Physician. 2005;34:157–61
• Backous DD, Duke W. Implantable middle ear hearing devices: current
state of technology and market challenges. Curr Opin Otolaryngol Head
Neck Surg. 2006;14:314–8.
• Lloyd S, Meerton L, et al. Taste change following cochlear implantation’,
Cochlear Implants International, 2007;8:203–10
• https://www.audiologyonline.com/articles/cochlear-implants-considerat
ions-in-programming-1011