With modern hearing aids, wireless hearing assistance, and cochlear implants, children with all degrees of hearing loss are learning to listen and talk like their hearing friends, even before entering preschool.
Because of this rapid evolution of technology, many of us have found it difficult to stay true to our roots and provide cutting-edge auditory-based habilitation/rehabilitation that optimizes patients’ ability to use the technology.
A dream team for serving a child with hearing loss who will listen and talk should include parents, a pediatric audiologist, and a speech-language pathologist or educator of the deaf with the Listening and Spoken Language Specialist (LSLS) credential. A speech-language pathologist certified as a Listening and Spoken Language Specialist in Auditory-Verbal Therapy (LSLS Cert. AVT) is experienced in coaching families to be the primary teacher.
Unfortunately, dream teams are still not the norm because of a well-documented shortage of LSLS professionals needed to serve the 20,000 children age 0-5 whose parents will seek such services each year in the United States—a conservative estimate (Oberkotter Foundation http://connectededucators.org/wp-content/uploads/gravity_forms/8-8452cee04fc80fe103b7ba5a4106bac7/2013/10/2013-08-OberkotterBrief.pdf).
We believe that every pediatric audiologist should be equipped with a “tool bag” of auditory-verbal strategies that are easy to remember, simple to convey, and effective in facilitating auditory skill and spoken language development for children with hearing loss. This month's installment of the Tot Ten will outline our top strategies.
We dedicate this column to mentors who instilled in us a passion for teaching children to listen and talk, including, but not limited to, Warren Estabrooks, Carol Flexer, and Judy Simser.
1. EYES OPEN, EARS ON
All too frequently, families are told that the duration of hearing aid wear should increase from one hour a day to eight hours a day over a three-month period so that the child can get used to the hearing aids.
However, for children to have excellent listening and spoken language outcomes, they should be wearing well-fitted hearing aids or cochlear implants during all waking hours. Even parents of our smallest babies are coached that if the hearing aids or cochlear implants are not worn, their child is missing out on critical opportunities for brain development.
Parents are also coached to check a child's technology diligently to make sure it's not malfunctioning.
2. BE A BIRD DOG
We coach families to track down sounds and to label and seek their sources. For example, parents and caregivers may point to their ears and say, “I hear Daddy's knock on the door; let's go open the door.” “I hear the dog barking.” “Listen, my phone is ringing.”
As the child grows and a family's awareness is heightened, parents are coached to expect their child to be a listener. On a walk through the neighborhood, a parent might stop in front of the home of a barking dog, pause, point to his or her own ear, and say, “Listen, I hear a dog. That dog is barking. That dog is barking loudly. Shhh, noisy dog! I hear that noisy dog.”
Families as well as professionals who successfully use this strategy often find themselves in other settings, perhaps without a child present, walking into a room and pointing out sounds to anyone standing nearby. Be careful….
3. HEAR IT BEFORE YOU SEE IT
Often called audition first, this strategy is a reminder that children with hearing loss need extra opportunities to experience the sound of words through listening before they see the words as spoken.
Parents are coached to play naturally, hiding toys in a box and describing them before the child has a chance to see and play with the toy. A parent might say: “Oh, wow. This is going to be so much fun. It's a toy that goes round and round. It spins round and round.”
By pausing and perhaps singing about the toy before showing the top to the child and allowing him or her to engage with it, the parent gives the child lots of auditory experience with the top before he or she is able to experience it with all the senses. The parent also can support natural conversation while maintaining joint attention on the activity by sitting next to, rather than across from, the child.
In their landmark study, psychologists Betty Hart and Todd Risley found that typical children have the opportunity to hear 45 million words by the time they are four years old. (Meaningful Differences in the Everyday Experience of Young American Children. Baltimore, MD: Paul H. Brookes Publishing; 1995.) It's critically important that parents of children with hearing loss are coached to pour words into their children at every opportunity.
Just as a radio announcer gives a play-by-play account of a football game, parents are coached to give play-by-play accounts of their child's day: “It is time to eat. I know you are hungry. Today, let's have yogurt. The yogurt is in the refrigerator. I am opening the fridge to find the yogurt. Uh-oh, your sister ate all of the blueberry yogurt. I hope you like peach yogurt. It is yummy.”
As children grow, it is still important to talk out loud because we are exposing them to the early development of Theory of Mind (ToM), teaching them that others have thoughts different from their own.
When a child hears a parent say, “Where are those car keys? I can't believe I lost them again. I'm so embarrassed I lost those keys again,” it is yet another opportunity to build ToM in a child with hearing loss.
5. IT'S YOUR TURN
Even with the youngest of our little ones, it is important to begin the dance of turn taking. Over the years, we have met many children who had excellent articulation and even vocabulary but were unable to engage in a lively conversation because responses were not expected. They didn't understand the give-and-take of a conversation.
“It's your turn” is all about expecting a response from the child—pausing, waiting, leaning in, and looking expectantly for at least five seconds. Should there still be no response, asking the same question of a family member who will then model the behavior is an effective way to elicit a response.
When we greet children in the waiting room, a response is always expected. If the response is a stare, often we will turn to the parent and say, “Hi, how are you today, Mom?” to which she responds, “Hi, I'm great.” The odds are high that when we then turn back to the child, the child will respond to, “Hi, how are you,” with, “Hi, I'm great.”
If none of the techniques used to indicate it's the child's turn work, a parent might lean in and say, “You could say, ‘Hello, I'm great.’” If the child imitates, the behavior is reinforced with the words, “I'm great, too.”
6. KEEP ‘EM ON THEIR TOES
Another very effective strategy is the use of sabotage. Even little ones recognize when something is amiss, like when a child asks for a drink and a parent pours the juice with the lid still on. Pouring only one drop of milk in the cup and handing it to the child may cause a look of shock, but, more often than not, it is an opportunity for the child to use the word “more” or say, “I want more milk.”
Sabotage can also take the form of pulling up a high chair as a seat for the mother or removing all chairs from the mapping or fitting room.
7. MAKE IT EASIER
We know that background noise from the television, radio, or siblings can negatively affect the child's ability to hear. With “make it easier,” we modify the listening environment by turning off the television or moving closer to the child.
Another way we can make it easier for a child to hear is through acoustic highlighting, which emphasizes a particular sound, such as the /s/ in “ducks.” Whispering is another form of acoustic highlighting.
Frequently, we sing to make it easier for a child to hear. Parents often are a bit embarrassed about singing in a session, but, once they see that it is not the quality of the music that matters but the fact that melody and prosody make things more salient for their child, even some of the most reserved fathers begin making up their own songs to familiar tunes: “This is the way we brush your hair, brush your hair, brush your hair. This is the way we brush your hair when we go to school.”
In addition, instead of asking an open-set question (“What do you want to eat?”), asking a closed-set question (“Do you want nuggets or turkey?”) makes it much easier for preschool children to answer, given their limited vocabulary. Of course, the goal is to expect more of the child by increasingly asking open-set questions.
8. BEYOND THE HERE AND NOW
Through the use of expansions and extensions, we can bring in personal stories about what happened in the past or what might happen in the future.
If a child says, “I want the ball,” an expansion might be, “I want the big red ball.” An extension could be, “I had a red ball when I was a little girl, but my dog tore it up. My dog was naughty.”
Children love to hear stories about what they did when they were babies, and they love to hear silly stories about others, particularly their parents or even their favorite audiologists.
Embellishment of a story is a great way to keep children's interest and give them an opportunity to ask questions or talk about events that happened outside the therapy suite or mapping room.
A quick word of caution; be sure that your colleagues or the parents of the child realize that the story is embellished. Your reputation may be tarnished by some of the embellished stories told and heard throughout a busy clinic.
9. HELP ME, BUT DON'T TELL ME
As children grow and their receptive and expressive vocabulary increases, it is important for the team to continue to set the bar high.
Parents often need encouragement to use new and different vocabulary, such as “exhausted” for “tired,” rather than settling for the word they know their child understands.
Playing guessing games that include categories, such as, “It's a fruit that is red and grows on trees,” or, “Our friends have a new pet that rhymes with hat,” also helps children without telling them. Using opposites is another technique that can cause a child to think: “I have something that I use in the kitchen to cut the meat. It is not dull.”
10. WHAT DID YOU HEAR?
Children with hearing loss can get into the bad habit of asking “huh” and “what” when unsure about what they've heard. Parents and caregivers often repeat themselves, and, before long, the pattern reinforces that a child needs four repetitions and doesn't have to listen the first time.
Asking “what did you hear” is an excellent technique to develop better listeners. It is important that the phrase be “what did you hear” rather than “what did I say” as there is no right or wrong answer to the former question.
For example, if asked, “What's your favorite ice-cream?” the child might answer, “Huh?” When the parent asks, “What did you hear?” and the child replies tentatively, “Ice-cream?” the parent replies, “Good for you; you heard ‘ice-cream.’ I said, ‘Let's go get ice-cream,’” thus boosting the child's confidence that what he heard was right.
Both the Listening and Spoken Language Specialist and the pediatric audiologist can gather a great deal of information diagnostically about the child's auditory skill development through the use of “what did you hear.”
As pediatric audiologists, we have the privilege of bringing the world of sound to children through modern hearing aids, wireless hearing assistance technology, and cochlear implants. Our hope is that these auditory-verbal strategies will help you guide and support families as they bring the sounds of life to their children.