Auditory verbal therapy is an early intervention program that trains parents to maximize their hearing impaired child's speech and language development through normal age-appropriate communication using the auditory sense. The therapy focuses on developing listening, speech, language, and communication skills through play-based activities guided by principles of auditory development, parental guidance, and use of hearing technology to access all sounds. Auditory verbal therapists work one-on-one with parents and children to coach parents as the primary facilitators of their child's listening and spoken language development.

1. Auditory verbal therapy
AMIT KUMAR MAURYA
AUDIOLOGIST AND SPEECH THERAPIST
TREE TOP HOSPITAL, MALDIVES

3.  How will I communicate with my child ?
 How will my child communicate as a normal child?
 How will I find a program that will help prepare my child
academically, socially verbally?
 As we know there are numerous options to improve and
rehab for hearing impairment children but AVT is major
and crucial strategy.

4.  1n 1977, A group of clinicians who advocated the auditory approach met in Helen Beebe speech and
hearing clinic and in 1978 it was decided to form a special committee called the International committee
on auditory verbal communication based on the principle of Acoupedics. The term Auditory-Verbal was
suggested by Daniel Ling.
 AVT is highly specialist early intervention program which equips parents with the skills to maximize their
Hearing impairment child’s speech and language development to age appropriate.

5. Basic tenets..
 Most children have sufficient residual hearing.
 If child hears all the sounds through amplification he has the
opportunity to develop language in a natural way through
auditory modality.
 All Infants and toddlers learn language the most efficiently
through consistent and meaningful interactions in a supportive
environment with significant caregivers.

6. Essence of auditory training
 Auditory sense is the fastest, easiest & most direct means to acquire the spoken language in hearing
impairment child.
 Normal speech & language develop as result of auditory input combined with communicative
experience.
 Auditory channel – self monitoring of speech.

7.  Hearing impairment child have a
normal central auditory nervous
system, the brain’s capacity to
process spoken language is
assumed to be normal.
 Thus the critical factor in the
acquisition of oral language for
children with Hearing impairment
is the amount & quality of auditory
sounds & experience.

8. 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) are 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

9. 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.

10. Principles of Auditory-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 of their child's listening and spoken language
development through active consistent participation in individualized Auditory-Verbal Therapy.

11. Principles of Auditory-Verbal Therapy
 Guide and coach parents to create environments that support listening for the acquisition of spoken
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 10 principles.

12. Environment for AVT
 Method of teaching- one on one, individualized teaching
developmental approach (hearing age)
 Attitude-emphasis on audition
 Atmosphere-fullest opportunity to use residual hearing,
surrounded by people who expect him to listen and respond
and show him how to communicate normally.

13. 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.

14. 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. (inverse square Law)
 Audiogram/aided audiogram

15. Planning therapy (lesson plan adapted from Shepherd Centre)
 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

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

17. Stages of AVT
Awareness or
Detection of
Sound
DiscriminationIdentification
Comprehension

18. 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.

19. 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.

20. 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/

21. Comprehension
 Understanding of speech
 Usage of speech in right form can be made by building Language comprehension
and expression.

22. Process/Practice
 Verbal Therapist works one-on-one with parent/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

23.  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.

24. AUDITORY-VERBAL TECHNIQUES
 The following are some of the techniques used in Auditory-Verbal education to enhance a child’s
listening, speech and language skill.
 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: “What is the hand cue and why do we use it?” “Do we block the
acoustic signal?” “Is it used in school?
 ACOUSTIC HIGHLIGHTING: It is earliest form of acoustic highlighting used is called
“Motherese” or “Parentese.” It is speech used by parents/caregivers in talking with young children to
make speech more audible to help them in learning language.
 Research by “Dr. Patricia Kuhl” indicates that parents is universal and plays a vital role in helping
infants analyses speech. The use of early highlighting is an auditory technique that is extended in
communicating with the beginning hearing aid or cochlear implant user to increase the audibility of
language. As a child learns to listen, the aim is to progress towards a more normal, less highlighted
mode of communication

25.  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.
 In auditory directions, asking children to imitate what they heard, discourages guessing as it serves to verify
what the children heard before attempting the task
 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.
 When a child has developed some spoken language through hearing and is not attending well to auditory input
he/she may respond to auditory input with “What?” or may sit there with a blank expression on his/her face.
To emphasize listening, pause and then ask, “What did you hear?” This technique helps the child how develop
clarification skills.
 You may discover that they have heard you and will respond appropriately or they will clarify by telling how
much of the input they grasped

26.  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.
Only too often a child and his family experience failure because targets are too difficult and do not follow
a natural sequential order.
 In developing speech through hearing, a developmental program is used. Initially, variations in vowel
content and suprasegmental offer good acoustic contrast aiding in speech perception.

27. 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.

28. Audiological Pre-assessments
In order to determine if a child is audiologically a candidate for a 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 soundfield testing
 Otoacoustic emissions
 Evoked auditory brainstem response
 A number of speech perception tests

29.  Remember: Audiology is only one
part of the assessment process. A
multidisciplinary team determines a child's
candidacy for a cochlear implant.

30. 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.

31. 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).

32.  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.

33. Evaluations
 In addition to routine Mapping, all children
with cochlear implants are followed at regular
intervals to assess speech perception abilities.
 These assessments include an audiogram in
sound field with the cochlear implant as well as
the battery of speech perception tests. These
evaluations occur annually.