1. Facilitating spoken language development in the regular classroom September 28 th & 29 th Winnipeg, MB Petra Smith M.Sc. Aud (C) Audiologist/Certified Auditory Verbal Therapist

2. AV PRINCIPLES AND THE AV SESSION How the auditory verbal therapist works with the children, their families and other professionals

3. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Auditory Verbal Services in Manitoba: 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

4. 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

5. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Auditory Verbal Therapist – experience & training SPEECH LANGUAGE PATHOLOGIST EDUCATOR of children who are deaf or hard of hearing AUDIOLOGIST Certified by A G Bell: Listening and Spoken Language Specialist www.agbellacademy.org

6. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Standardized Curriculum for Trainee Therapists: History & Philosophy Hearing & Audiology Spoken Language Development Parent Guidance Cochlear Implants Education in the mainstream Auditory Verbal Practice

7. 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.

8. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Auditory Verbal Therapy.. …..is part of the Auditory Verbal Approach

9. 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

10. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Ten Principles of AVT Adapted from the principles developed by Doreen Pollack, 1970 Adapted by the A G Bell Academy for Listening & Spoken Language, 2006 www.agbellacademy.org

11. 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”

12. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Hearing vs Listening (Flexer, 2005) Hearing is acoustic access to the brain. It includes improving the signal to noise ratio by managing the environment and utilizing hearing technology. Listening is attending to acoustic events with intentionality.

13. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Hearing loss Hearing loss is not about the ears; it is about the brain. Hearing aids, FM systems and cochlear implants are not about the ears; they are about the brain (Flexer, 2005)

14. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Functional impact of hearing loss: distance hearing Flexer 1999

15. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Functional impact of hearing loss: incidental learning Flexer 1999

16. 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

17. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Neuroplasticity 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

18. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Typical Language Development Means.. Optimal use of the brain for skills human beings are pre-disposed to acquire – ie: spoken language Best opportunity to achieve success in areas which must be taught – ie: reading

19. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Implications for Intervention Developmental approach …instead of…. Remedial approach

20. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 GOAL: Universal Newborn Hearing Screening

21. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Goal – at identification  Support families in making their decisions about:  Language of choice  Communication approaches

22. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Communication Options:

23. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 ManualOral SignSpokenLanguage (ASL)(English/French etc)  ---------------------------------------------------------------------  Bi-bi Auditory Verbal Signed Exact EnglishAural-oral Total CommunicationCued Speech

24. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 AV therapist offers  Time to reflect, question, feel, grieve  Information – re:  Technology  Hearing  Spoken language development  General developmental issues  Action – what to do!  Contact with other families

25. 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”

26. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 A good acoustic signal is needed for auditory stimulation

27. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Amplification – improves quantity and quality of acoustic signal

28. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Good audiological support Early identification of hearing loss Accurate diagnosis Optimal amplification Early intervention

29. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Early amplification 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

30. 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.

31. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Advanced Bionics 90k Implant

32. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Speech Processors from Advanced Bionics

33. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Wireless FM with iConnect earhook

34. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Freedom Speech Processors from Cochlear Corporation

35. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 MicroLink Freedom for the BTE Seamlessly integrated into the BTE case FM receiver can be left in place all the time

36. 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”

37. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Is motivated Has time and opportunity Is attentive A person who really listens

38. 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

39. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 AV Goals – infants & toddlers 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

40. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Assess, monitor & facilitate:  Auditory development: awareness of sound attaching meaning to sound vocalizations  Eye gaze & joint attention  Development of natural gesture  Play

41. 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.”

42. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Parental Involvement Parents are the child’s: Primary language models First teacher Playmate Advocate

43. 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

44. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Why individualized therapy?

45. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 CONVERSATION Social interaction Problem solving and thinking Negotiation and sharing Story telling Joint imaginary play Why do children need language?

46. 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

47. 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..

48. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 How hard can it be?

49. 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?

50. Petra Smith M.Sc. Aud (C) Sept 28/29 2009

51. A good conversation… Now think of someone you enjoy having a conversation with. What do they do that makes it so worthwhile?

52. Petra Smith M.Sc. Aud (C) Sept 28/29 2009

53. The rules of conversation: 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

54. Petra Smith M.Sc. Aud (C) Sept 28/29 2009

58. The underpinning to conversation is… …equally shared participation Like a game of table tennis….

59. Petra Smith M.Sc. Aud (C) Sept 28/29 2009

61. But… What if one of the participants isn’t very competent?

62. 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

63. Petra Smith M.Sc. Aud (C) Sept 28/29 2009

65. 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 If left unattended..can result in the child…

66. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 The usual solutions adopted by adults can feel very unsatisfactory, such as: 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

67. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 To avoid this families need: Information – sensitive to adult learning styles, literacy levels etc Demonstration – observation and participation Experience – practice and feedback

68. 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

69. 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”

70. 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.”

71. 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).

72. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 So….. The children need access to spoken language

73. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Enhancing listening Can modify:  environment  acoustic signal  interactions …..more later….

74. 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”

75. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Everyday life – more resources for families ………

76. 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.

77. 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”

78. 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

79. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 AUDITION & SPEECH ACOUSTICS Factors affecting speech intelligibility: timing of onset of deafness nature & extent of hearing loss type & appropriateness of amplification speech perception communication option chosen for the individual child other challenges

80. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Early identification allows.. Less delay More natural development More acceptable speech patterns Better literacy outcomes

81. 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”

82. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Spoken Language Follow developmental sequence in: RECEPTIVE LANGUAGE EXPRESSIVE LANGUAGE PRAGMATICS PHONOLOGY COGNITION

83. 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’

84. 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”

85. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 AVT in school – AV goals & the curriculum IEP Team involvement Collaboration with classroom teachers, resource teachers, SLPs etc Training for EAs Ongoing therapy sessions as needed Regular assessment & monitoring

86. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Outcomes of the Auditory Verbal Approach

87. Petra Smith M.Sc. Aud (C) Sept 28/29 2009

88. Early intervention outcomes 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.

89. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Geers et al (2003) 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) Outcomes measured by assessments normed on hearing population (speech perception; speech production; spoken language; total language; reading)

90. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 Geers et al – Findings: 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

91. 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

92. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 AVT..a therapy session.. 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……

93. Petra Smith M.Sc. Aud (C) Sept 28/29 2009 MOTIVATION GOALS CONTENT Therapy session framework

94. 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: THEME based planning – activities with a common topic (less structure) SKILL based planning (more structured) ACTIVITY based planning (daily routines)

95. Petra Smith M.Sc. Aud (C) Sept 28/29 2009