1. Auditory-Verbal Therapy and Cued Speech Alexandra D. Costlow, B.S.

2. Review: What’s the Difference between Auditory-Verbal and Oral-Aural? Auditory-Verbal Utilizes residual hearing and speech. The child is taught to listen first, and is not required to attend to visual cues. Early identification. Consistent use of optimal amplification. Mainstreamed from the beginning. Oral-Aural Utilizes residual hearing, speech, and sometimes lip-/speechreading. Early identification. Consistent use of optimal amplification. Mainstream the child after participation in special education. (Family Support Connection, 2001)

3. Foundations of Auditory-Verbal Therapy Promotes acquisition of spoken language through listening. Early diagnosis and audiologic intervention (usage of residual hearing, hearing aids, FM system, cochlear implants, etc..) are encouraged. One-on-one therapy. Parents/caregivers become primary facilitators through guidance, coaching, and demonstration. Who is the targeted audience for A-V therapy? Newborns, infants, toddlers, and young children. (Alexander Graham Bell Association for the Deaf and Hard of Hearing, 2005)

4. A Note on Alexander Graham Bell Association’s LSLS Certification AG Bell Academy for Listening and Spoken Language is the certifying organization for Auditory-Verbal therapists (LSLS Cert. AVT) and educators (LSLS Cert. AVEd.). “LSLS” stands for “Listening and Spoken Language Specialists.” LSLS Certification requires “ … Formal education, supervised practicum, professional experience and post-graduate study,” as well as 3 years of work with a LSLS certified mentor prior to passing the LSLS Written Test (Alexander Graham Bell Academy, 2005). To request an application: http://nc.agbell.org/NetCommunity/docs/HTML/AcademyLSLS/certification_register.htm

5. LSLS 10 Principles of Auditory-Verbal Therapy 1. Early diagnosis, followed by audiologic management and AV- therapy. 2. Immediate assessment and appropriate usage of hearing technology to maximize benefit of auditory stimulation. 3. Teach* parents** to use audition as the primary mode of communication. 4. Teach parents to become the primary facilitators of the child’s listening and spoken language. 5. Teach parents to create environments that scaffold the child’s development of listening and spoken language through his/her daily activities. (Alexander Graham Bell Association for the Deaf and Hard of Hearing, 2005)

6. LSLS 10 Principles of Auditory-Verbal Therapy 6. Teach parents to help integrate listening and spoken language into all areas of the child’s life. 7. Teach parents to use natural developmental, cognitive, and communicative patterns. 8. Teach parents to teach their child to auto-monitor spoken language through listening. 9. On-going formal and informal assessment should be integrated into the A-V therapy plan. Promote mainstream education with appropriate assistive services from early childhood on forth. (Alexander Graham Bell Association for the Deaf and Hard of Hearing, 2005)

7. Let’s Observe Auditory-Verbal Therapy http://www.youtube.com/watch?v=mFUUegLsF_w What elements of A-V therapy do you observe?

8. The Basics of Cued Speech Cued speech supplements spoken English by providing manual cues to make important features of spoken language fully visible. 8 hand shapes in 4 locations, combined with the natural visual cues of mouth movements. Shapes using one hand identify consonant sounds. Cues near the mouth identify vowel sounds. Thus, a hand shape + a location = a syllable. (Georgetown University Medical Center’s Center for the Study of Learning) According to Brown in Katz, Medwetsky, Burkard, and Hood (2009), about 60% of English phonemes are invisible through speechreading.

9. Who Uses Cued Speech? Children and adults with hearing, speech, and language needs. Families, friends, caregivers, and professionals who interact with people with hearing, speech, and language needs. Adults who are hearing impaired use cued speech to supplement their residual auditory skills. Adults with sudden or progressive hearing loss. Cued speech is used for phonics instruction, articulation therapy, and special education. (Georgetown University Medical Center’s Center for the Study of Learning)

10. According to the NCSA … The National Cued Speech Association (NCSA) describes that cued speech “ … Provides access to the basic, fundamental properties of spoken languages through the use of vision.” When was it developed? It’s functionality is not limited to English. How many languages can use it? What is the primary goal of cued speech?

11. Let’s Learn about Cued Speech from the NCSA www.cuedspeech.org/ http://www.youtube.com/watch?v=B9emmTMswkE

12. Outcome Survey of Clinical Efficacy of AVT Goldberg and Flexer (2001) described goals of AVT practice Develop auditory neural centers through [amplified] residual hearing Allow deaf or HoH (hard of hearing) children to grow up in “typical” learning and living environments Enable children to live independently in mainstream society (p. 407) Goldberg and Flexer (2001) attempted to contact all known auditory-verbal centers (9) and all certified AVT therapists in the United States and Canada (approximately 200) (p. 408).

13. Goldberg & Flexer (2001)Subjects Subjects met the following criteria: Were 18 years or older Had participated in therapy for at least 3 years All subjects participated in survey research Open- and closed- ended questions Degree and etiology of hearing loss Age of onset Use of amplification/sensory aid technology Education and employment history

14. Goldberg & Flexer (2001) Stats Response rate of 36%, yielding 114 usable forms 94% of the respondents reported having a severe to profound hearing loss 95% reported having hearing loss since birth (n=40) or before age 3 (n=66) = prelingual hearing loss 66% were amplified by 3 months and 82% (cumulative) were amplified by 6 months from age of diagnosis 69% were binaural hearing aid users, 14 (subjects) were monaural, 8 used a unilateral cochlear implant, 1 used bilateral cochlear implants, 8 used CI + HA, 2 wore FM/HA, and 2 did not use amplification Mean age of respondent was 28.9 years (range= 18 to 56)

15. Goldberg & Flexer (2001)Results Does AVT lead to it’s goals? Subjects were identified and amplified early, and enrolled into early intervention programs that had auditory foci and were family-centered. This resulted in a high-degree of mainstreaming, normal high school graduation, and routine post-high school education. Subjects were able to have a variety of employment opportunities and were integrated into society in general (p. 412). 60% of working subjects had an income of $25,000 or more. 98% of subjects went on to college/university education compared to 60% of the general population and 46% of deaf or HoH (p. 413).

16. Goldberg & Flexer (2001)Food for Thought Sample Considerations: Early identification and intervention, high percentage are amplified, did only the satisfied respond? Goldberg and Flexer (2001) suggest that graduates beginning AVT in the late 1940s onward have achieved independence in mainstream society (p. 413). “The sky is the limit” re: early identification and intervention + current and improving amplification technology AVT graduates are the “Anonymous deaf” in society (p. 413).

17. Dornan, Hickson, Murdoch, and Houston (2009) examined: Speech development Language development Speech perception Tested initially, and then re-tested 21 months later Longitudinal Study of Speech Perception, Speech, and Language Tasks for Children with Hearing Loss in an AVT Program

18. Dornan et al. (2009)Subjects Subjects 25 children (18 males, 7 females) with mean pure tone average of 79.37 dB HL in an AVT program Mean age of identification was 24.6 months 10 wore bilateral hearing aids and 12 wore HA + CI, remainder were unilateral HA (1) or CI (2) Subjects matched to control group with normal hearing for the following characteristics: Initial language age Receptive vocabulary Gender Socio-economic level

19. Dornan et al. (2009)Results Significant improvement for both normals and subjects with hearing loss in the following categories: Auditory comprehension (PLOT; PBK; CNC; Bamford, Kowall, and Bench – BKB sentences) Oral expression Total Language (PLS-4, CELF) Articulation of consonants (GFTA-2, Computer Aided Speech and Language Analysis- CASALA) *Speech perception (for monitored live voice, but NOT recorded material) **There was NOT a significant difference in performance between the subjects with hearing loss and normals.

20. Dornan et al. (2009)Results, Continued Initially, 58.6% of children with hearing loss scored within the normal range for total language assessment whereas 84% of these subjects scored within the normal range at the 21-month mark. Subjects with normal hearing improved significantly more in the receptive language (PPVT-3) measure than did subjects with hearing loss. However, both groups scored within the normal range.

21. Dornan et al. (2009)Food for Thought Overall, subjects with hearing loss illustrated improved speech perception scores over the 21-month period of investigation. The rate of speech and language development for children with hearing loss was similar to that of their normal hearing peers. Do these results support the goals of AVT?

22. Relation between Deaf Children’s Phonological Skills in Kindergarten and Word Recognition Performance in First Grade AKA, how does cued speech affect language development between kindergarten and first grade in Deaf children in comparison to language development in their Hearing peers? Subjects: 21 Deaf (11 males, 10 females) children with severe to profound prelingual hearing loss 8 use CIs, 13 use HAs Mean age = 6 years; 2 months No other handicapping conditions 21 Hearing (11 males, 10 females) Mean age – 6 years; 1 month

23. Colin, Magnan, Ecalle, &Leybaert (2007) Exposure to Cued Speech (Deaf children) 7 from age 25 months at home 7 from age 56 months in school and inconsistently at home 7 upon entering first grade

24. Colin et al. (2007)Method Session I (Kindergarten) Rhyme Decision Task (Which one doesn’t rhyme?) Rhyme Generation Task (Name as many words as you can that rhyme with ______) Measured speech intelligibility Session II (First Grade) Rhyme Decision Task (Which one of the three shares the same syllable or initial or final consonant as the model?) Phonological common unit identification task (State aloud the unit shared by the model and choice) Written word choice task (Choose the correct written word out of 5 choices)

25. Colin et al. (2007)Results Results The Hearing group achieved a higher degree of accuracy in all experimental tasks than did the Deaf group. Chronological age, non-verbal IQ, hearing loss, speech intelligibility, and age of exposure to cued speech do NOT have a significant effect on the phonological skills in kindergarten. Degree of hearing loss was significantly correlated to epi-phonological skill. Age of exposure to cued speech predicted only written word recognition ability at the end of first grade. Age of exposure to cued speech significantly affected phonological skill and meta-phonological skill in first grade. Written word recognition score was predicated only by age of exposure to cued speech (after controlling for chronological age and IQ).

26. Colin et al. (2007)Discussion The benefit of early exposure to cued speech is not seen until later in development. Young children are not aware of the purpose of cued speech, to provide phonological cues. This becomes helpful with speech intelligibility and word recognition tasks.

27. Visual Speech in the Head: The Effect of Cued-Speech on Rhyming, Remembering, and Spelling “Deaf children exposed early to CS at home show a reliance on inner speech for rhyming, remembering, and spelling similar to that displayed by hearing children but different from that of deaf children not exposed early to CS. We argue that the degree of specificity of phonological information delivered to the deaf children is more important than the modality though which they perceive speech for the development of phonological abilities” (Leybaert & Charlier, 1996, p. 235). Why are these abilities important? Why is this difference significant?

28. Leybaert & Charlier (1997)Results/Implications Given adequate input, Deaf children can acquire phonological representations and inner speech processes similar to those of Hearing children. Acoustic experience is not necessary to develop phonological processes. Information delivered through the visual modality (cued speech) may trigger these processes. Accurate and specific information about the phonological contrasts of spoken language is key. Exposure to lip-reading only is not specific enough to trigger these processes.

29. Leybaert & Charlier (1997)Results/Implications Exposure to cued speech at home is key. At school is not enough. Children who use cued speech at school only do not use it to the same extent nor with as good accuracy. Consideration: Do children who use cued speech at school only lack linguistic experience? Consideration: Does quality of language differ between home and school? Consideration: Does age of exposure affect phonological ability?

30. References Alexander Graham Bell Association for the Deaf and Hard of Hearing. (2005). AG Bell Academy for listening and spoken language. Retrieved from Alexander Graham Bell Academy for Listening and Spoken Language website: http://nc.agbell.org/netcommunity/academy/ Alexander Graham Bell Association for the Deaf and Hard of Hearing. (2005). Principles of LSLS auditory verbal training. Retrieved from Alexander Graham Bell Academy for Listening and Spoken Language website: http://nc.agbell.org/NetCommunity/page.aspx?pid=359 Brown, A.S. (2009). Intervention, education, and therapy for children who are deaf or hard of hearing. In J. Katz, L. Medwetsky, R. Burkard, & L. Hood (Eds.), Handbook of clinical audiology (pp. 934- 969). Baltimore, Maryland: Lippincott Willliams & Wilkins. Colin, S., Magnan, A., Ecalle, J., & Leybaert, J. (2007). Relation between Deaf children’s phonological skills in kindergarten and word recognition performance in first grade. Journal of Child Psychology and Psychiatry, 48 (2), 139-146. Dornan, D., Hickson, L. Murdoch, B., &Houston, T. (2009). Longitudinal study of speech perception, speech, and language for children with hearing loss in an auditory-verbal therapy program. Volta Review, 109(2/3), 61-85. Family Support Connection. (2001). Aural-oral communication. Retrieved from Family Support Connection website: http://www.familysupportconnection.org/html/aural.htm.

31. References, Continued Georgetown University Medical Center’s Center for the Study of Learning. Cued speech online information packet. Retrieved from Georgetown University Medical Center website: http://csl.georgetown.edu/info_packets/CuedSpeechIndex.shtml Goldberg, D. M., & Flexer, C. (2001). Auditory-verbal graduates: Outcome survey of clinical efficacy. Journal of the American Academy of Audiology, 12, 406-414. Hearts for Hearing (Producer). (2009). Michael CA 8 years [video]. Available from http://www.youtube.com/watch?v=mFUUegLsF_w Leybaert, J., & Charlier, B. (1996). Visual speech in the head: The effect of cued-speech on rhyming, remembering, and spelling. Journal of Deaf Studies and Deaf Education, 1(4), 234-248. National Cued Speech Association (NCSA). What is cued speech? Retrieved from the NCSA website: http://www.cuedspeech.org/ Ruberl, A. (Producer). (2008). What is cued speech? [Video]. Available from http://www.cuedspeech.org/