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Learning how to listen while coming of age - Auditory Verbal Training

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Learning to listen while coming of age
Ellen A. Rhoades, Ed.S., Cert AVT
Auditory-Verbal Training/Consultation Services International
Neurology of hearing.
Neuroscientific findings inform us that unused auditory neurons atrophy over time, and
the adult brain does not replace lost neurons (e.g., Rakic, 2004). However, the field of auditory
neuroscience is still in its infancy and we have much to learn about the plasticity of the human
brain, including neuronal replacement in adulthood. While research findings are unequivocal in
that the brain experiences its greatest period of auditory growth during the first few years of life
(e.g., Pulsifier, Salorio, & Niparko, 2003; Sharma, Dorman, & Spahr, 2002), findings show that
auditory neural networks can be newly established throughout adolescence and even adulthood
(e.g., Rakic, 1998).
Brain activity increases as new information is learned, and then diminishes as the new
information becomes better learned. Indeed, even though the learning process may be a bit more
time-consuming than with younger children, older brains can be re-sculptured by auditory
experiences (e.g., Robertson, 1999). Therefore, it is imperative that we engage adolescents in the
brain sculpting process as wisely and efficiently as possible.
Buying into the cochlear implant.
Cochlear implant (CI) technology can enable adolescents with congenital severeprofound deafness to easily access soft conversational sound at 30 dB HL and to attain a
respectable modicum of speech perception solely by way of the auditory channel. This has been
repeatedly demonstrated by researchers and is becoming widely recognized by auditory-based
clinicians who assist older children with hearing loss (e.g., Koch, 1999; Rhoades, 2001). As
more primary caregivers observe the successes of young implant users, more are encouraging
their older children to take advantage of this hearing technology. Given that BTE CI processors
are similar to BTE hearing aids in size, even adolescents who claim comfort in their deafness are
increasingly expressing interest in this option; their frequently stated reason is the desire to use a
telephone (Rhoades & Jovanovic, 2002).
Prior to actual implantation, when the opportunity for a cochlear implant is presented to
an older child, it is imperative that the student be a part of the decision-making process. The
clinician should ascertain what the student expects from a CI, perhaps tempering those unrealistic
expectations with more likely long-term realities. For example, it is unrealistic for the student
who embraces ASL to expect auditory-only understanding of spoken English unless he is willing
to be immersed in spoken English. Each student should buy into the process of learning to hear
before opting for cochlear implantation.
The pros and cons of implantation at various levels should be discussed with each
interested student. These include the understanding that, for the older child who has never heard
normally and who did not previously engage in any auditory-based intervention, the road to
understanding spoken language on a regular telephone may possibly be long, tedious, and
frustrating while requiring much motivation, perseverance, and practice. Yet, the student should
also understand that understanding spoken language face-to-face may be considerably enhanced
within a much shorter period of time.
Peers with cochlear implants should be called upon to exchange information with the
prospective implant user. This can serve to educate the student as to the many possible outcomes
as well as expand his social network and role models. When becoming fully cognizant of the
implications of such a highly personal decision, the student typically begins buying into the
empowerment process regarding his deafness, optimal use of his speech processor, and the
auditory-based intervention program to be subsequently implemented.
A comprehensive process.
For many students, obtaining a cochlear implant is clearly not enough. To optimize their
auditory potential, a comprehensive rehabilitative program should be implemented, particularly
for those who were visually-oriented prior to implantation. Unwisely, some insurance companies
do not underwrite the cost of rehabilitation, so therapeutic services cannot be obtained at some CI
centers. Consequently, school-based speech-language pathologists and audiologists are
increasingly being called upon to provide aural rehabilitation services.
Aural rehabilitation is a process comprised of more than just auditory training. Similarly,
many newly-implanted students require services above and beyond just learning how to listen
with their hearing prosthesis. Students who did not hear well with hearing aids often suffer from
the ramifications of deafness that include but are not limited to:
(1) Speech production that may not be readily intelligible due to poor voice quality such as
nasality or poor use of suprasegmental features such as arrhythmicity and lack of prosody;
(2) Controlling or otherwise poor conversational interactions with normally hearing peers,
often due to misunderstanding the art of conversation;
(3) Inadequate self-concept and psycho-emotional difficulties;
(4) Insufficient understanding of one‟s own learning and communicative difficulties and
possible ways to minimize those difficulties;
(5) Lack of knowledge about available hearing technology.
These issues are above and beyond any language delays or dysfunctions that may already be
exhibited by the student.
The student should be encouraged to embark on a self-discovery process toward
understanding both the pragmatic and psychosocial-emotional roles of deafness in his own life.
Many students are both inspired and enlightened when the process of learning to listen is
intellectualized, particularly when armed with information about current hearing technology and
self-knowledge. It is imperative that the clinician be forthright with each student, beginning with
the initial assessment process and continuing with ongoing counseling, education, and therapeutic
Analysis of each student‟s communicative interactive style is warranted. How persistent
are the student‟s attempts at oral communication? Does the student have a habit of using
controlling behaviors when attempts at conversation are made? Is the student aware of specific
difficulties and of those limitations imposed by his own deafness? Does the student demonstrate
knowledge of or use of effective conversational repair strategies? Is the student aware of
assistive listening technology and are any attempts made to take advantage of this? Are
pragmatic language skills in evidence? Does the student understand the need for minimizing
acoustic clutter? Is the child in the habit of bluffing, or pretending to understand what others say?
All of these issues should be discussed with the child.
The student must learn how to effectively obtain clarification, i.e., asking the nonspecific, general, neutral “What?” question is the least helpful of all learning strategies. Along
the same lines, while it is important for the child to use more effective repair strategies, it is
equally important to discuss the emotionally laden issues of deafness, irrespective of hearing
prosthesis. As we are often reminded (e.g., Hull, 1992; Wayner & Abrahamson, 2000), those
issues faced by people with hearing loss come with many implications. Feelings like
embarrassment, fatigue, tension, stress, self-pity, anger, and loneliness affect the student‟s overall
psychological health and quality of life. Ideally, strategies that are effective for coping with these
issues should be discussed with both student and caregivers.
Appropriate cochlear implant device terminology should be used, the basic process of
programming should be understood, and newly learned listening skills should be practiced daily.
Similarly, becoming knowledgeable about available technology that can make classroom learning
easier should be brought to the student‟s attention. Just as ongoing counseling should be an
integral part of each training session, so should the clinician enable students to develop new selfmanagement skills by way of self-discovery. Full student ownership of the hearing loss should be
a mandatory goal of every comprehensive aural rehabilitation program.
While activities to promote the student‟s speech perception and production can
encompass both synthetic and analytic strategies, it is imperative that all activities be auditorybased. As the student‟s listening skills improve, there should be a gradual movement toward
telephone practice, since this is a powerful motivating tool. It is important that the clinician
understand this rehabilitation process can be frustrating and discouraging at times, so the student
should be set up for continual motivation by at least one highly positive listening activity during
each session.
The clinician should take care to use speech patterns that are noticeably prosodic; speech
comprehension via the auditory channel is clearly easier when the clinician‟s voice is animated
and the tempo a bit slower. Moreover, the clinician should embrace the concept that her role is
multi-faceted so as to include being a facilitator, a counselor, an educator, an enabler, a motivator,
and even a temptress. Given the sometime arduous role that the newly-implanted student must
travel, the wise clinician will keep the brass ring of telephone usage in focus for the child.
There are a variety of additional analytic and synthetic listening strategies that are offered
by commercially prepared aural rehabilitation programs (e.g., Koch, 1999; Stout & Windle, 2001;
Tye-Murray, 1993), all of which can be employed with implanted students. Two particular
programs, designed specifically for the school-aged child with a cochlear implant (Sindrey,
2003), encompass auditory discrimination exercises that facilitate listening for ten-step
hierarchical minimal pairs. Each of these two very affordable Compass Card Programs comes
with an acoustic screen, CD, chips or cardholders, and a placement test. While use of these flash
cards, circle cards, lotto games, matrices, boards, and barrier games are typically enjoyable for
the student, some clinicians may find the preparatory task of cutting out the printed materials to
be cumbersome.
It might be wise to include some counseling, education, an analytic activity at either the
suprasegmental or segmental level, and a synthetic activity within most therapy sessions.
Counseling involves psychosocial issues of deafness, recognition of difficulties in communicating
with others, and effective conversational strategies. Education involves effective maintenance of
the cochlear implant system and other listening systems.
Some effective therapeutic strategies.
It is important that the newly-implanted student realize there is considerable
improvement in access to speech at soft conversational levels, particularly „within earshot‟ in
fairly quiet environments. The clinician should be seated next to the student‟s implanted side, so
that speech is presented within close proximity – a distance of no more than 6-12 inches from the
child‟s processor microphone. Whether or not a „speech hoop‟ or „hand cue‟ will be used is
entirely a personal matter of the clinician. Simply sitting next to the student while placing
visually interesting material on the table can be quite effective in promoting auditory-based
therapy. Moreover, asking the student not to speech-read assigns respect, trust, and responsibility
to that auditory learner.
Employing the „auditory sandwich‟ 3-step strategy is necessary for the clinician assisting
newly-implanted visually-oriented students. This means that the auditory signal is first presented.
Then, if the student is unable to understand the spoken language after no more than one or two
repetitions, the clinician should permit the child visual access to the same information, e.g., signs,
finger spelling, print, pictures, or speech-reading, whichever means that is most comfortable for
both clinician and student. Finally, the clinician repeats the spoken signal, auditory-only, for the
child‟s benefit. Auditory repetitions neurologically set up the brain to understand what has been
heard. Putting the speech signal „back into hearing‟ better enables the student to develop an
auditory memory for the spoken word.
Initially, one activity objective is to have the newly-implanted student develop auditory
recognition of high-frequency consonants that may not have heretofore been heard. Employing
the voiced-voiceless phonemic contrast can be a highly effective listening activity for many
students (see Rhoades, 2001 for a more detailed explanation of the activity). When initially
differentiating one group of consonants from another, the student should not be expected to
auditorially differentiate one specific consonant from another. Just being able to hear the voiced
consonants, as a group, as auditorially differentiated from voiceless consonants, also as a group,
can bring the student to the threshold of realization as to what is entailed in whispering.
Provide the student with a variety of web sites where auditory skills can be practiced
daily and independent of caregivers or professionals. The student will need to have access to a
computer with a good quality speaker. One web site that links to a variety of other sites for
practice in listening to sounds, words, sentences, and paragraphs is The student has likely experienced
considerable therapy during his preschool years and any suggestions to minimize at-home therapy
with primary caregivers may be well appreciated.
Re-attune the body.
Neural synchrony, temporal patterning, timing, sequencing, and rhythmicity are critical to
brain growth, auditory learning, speech perception, and speech production (e.g., Barkley, 1997;
Gee, 1999; Kristan, 1998; Lee & Todd, 2004). Listening becomes easier and may be better
internalized when the brain detects and processes auditory patterns. Rhythm or the lack thereof
appears problematic in the speech of many newly-implanted students, hence developing an
auditory-based internal sense of rhythm seems critical. Because the physical body is intertwined
with the process of auditory learning, movement can facilitate more rapid auditory-based learning
(Rhoades & Cobb, in press). So, in addition to those common-sense strategies and listening
techniques that are offered in commercially-prepared listening programs, a strong emphasis on
rhythmic movement should be integral to an effective comprehensive rehabilitation program for
newly-implanted students.
Developing speech fluency may be accomplished with analytic techniques at the
suprasegmental level, e.g., practicing how to say “a cup of coffee” like “acuppacoffee.” We know
that therapeutic activities for students learning to listen should hook up the brain to the muscles;
auditory explorations begin in the re-learning process. Therefore, engage in a variety of ThinkSay-Do games (Rhoades & Powell, under review) that take a synthetic approach to integrating
rhythm. These games can be played with one or a small group of students.
“Ali Baba and the forty thieves” is one such Think-Say-Do game. The student must first
learn to chant the words “Ali Baba and the forty thieves” in six beats. This may prove difficult for
those who have not yet mastered the art of speaking rhythmically, so a metronome may be needed
to visually keep the student on track. In this case, the student will need to chant Ali Baba on two
beats, and the on one beat, forty on another beat, and then thieves on two beats. When the student
can demonstrate improved speech fluency, then add body movements to the mix, e.g., clapping
hands 6 times during the first chant. Gradually add more body movements so that each chant
brings on another repetitive movement; for example, clap hands 6 times, and then snap fingers 6
times. Finally, at its most difficult level, the body movements synchronized with the chanting can
be done a la ronde, so that the student must change physical movements based on what the
clinician just did – after the fact. Because the language used in this Think-Say-Do game is simple
and repetitive, it is easy for the student to stay focused on the clinician‟s auditory-based language.
Still another Think-Say-Do activity for the student who needs to develop internal sense of
rhythm is the popular preschool “One potato, two potato” means of choosing who goes first. The
student learns to elongate the vowel production of „four‟ and „more‟ so that its rhythm is more or
less synchronized with the movement of one cupped hand over another person‟s cupped hand or
one‟s own mouth, as the case may be.
Because we know that music is clearly related to speech and language (e.g., Janata &
Grafton, 2003; Palmer & Pfordresher, 2003; Patel & Daniele, 2003), the clinician is advised to
engage the student in many activities that integrate cognition with prosodic spoken language and
body rhythm. This is more likely to develop auditory-based neural networks, interhemispheric
integration, and true integration of the student‟s sensorimotor systems (Webster, 1995).
In summary, aural rehabilitation is more than just learning to listen. It is re-attuning the
body to hear, think, feel, say, and do. The auditory-based clinician should do more than just
provide post-CI auditory training (see Figure 1). What the good auditory-based clinician should
do is lead the student to the threshold of his own mind. Empowerment and ownership should be
part and parcel of a post-implant integrative auditory-based training program for our students.
When these concepts become reality, then both clinician and primary caregiver must nonjudgmentally accept the loss of their control. It is at this point that the student can logically argue
his coming of age.
Reproduced with permission.
Rhoades, E.A. (2004). Learning to listen while coming of age. ASHA Division 9: Perspectives on
hearing and hearing disorders in childhood, 14(2), 4-8.
Figure 1.
Potential benefits of cochlear implantation for students:
Increased speech perception skills
Improved speech production, particularly in voice quality and suprasegmental features
Better knowledge and use of language, particularly in morphological markers
Improved self-management and coping strategies
Greater ease in academic learning
Possible usage of telephones without text
Overall greater ease in daily living
Barkley, R. A. (1997). Attention-deficit/hyperactivity disorder, self-regulation, and time: Toward a more
comprehensive theory. Journal of Developmental and Behavioral Pediatrics, 18, 271-279.
Gee, H. (1999). Backwards Bohemian Rhapsody. Nature, April 29. Retrieved May 11, 2004 from
Hull, R. H. (1992). Aural rehabilitation: Serving children and adults. San Diego, CA: Singular Publishing.
Janata, P., & Grafton, S. T. (2003). Swinging in the brain: shared neural substrates for behaviors related to
sequencing and music. Nature Neuroscience, 6(7), 682-687.
Kristan, W. B. (1998). He‟s got rhythm: single neurons signal timing on a scale of seconds. Nature
Neuroscience, 1, 643-645.
Koch, M. E. (1999). Bringing sound to life: Principles and practices of cochlear implant rehabilitation.
Bethesda, MD: York Press.
Lee, C. S., & Todd, N. P. A. (2004). Towards an auditory account of speech rhythm: Application of a
model of the auditory „primal sketch‟ to two multi-language corpora. Cognition, 93, 225-254.
Palmer, C., & Pfordresher, P. Q. (2003). Incremental planning in sequence production. Psychological
Review, 110, 683-712.
Patel, A. D., & Daniele, J. R. (2003). An empirical comparison of rhythm in language and music.
Cognition, 87(1), B35-B45.
Pulsifier, M. B., Salorio, C. F., & Niparko, J. K. (2003). Developmental, audiological, and speech
perception functioning in children after cochlear implant surgery. Archives of Pediatrics & Adolescent
Medicine, 157, 552-558.
Rakic, P. (2004). Neuroscience: Immigration denied. Nature, 427, 685.
Rakic, P. (1998). Young neurons for old brains? Nature Neuroscience, 1(8), 645.
Rhoades, E. A. (2001). The voiced-voiceless contrast: A therapy technique for the newly-implanted teen or
adult. Volta Voices, 8(6), 29-30.
Rhoades, E. A. (2005). A neurodevelopmental approach to AVT. The Volta Review, In preparation.
Rhoades, E. A., & Jovanovic, S. (2002, June). Auditory learning and telephone training for teens and
adults with cochlear implants. Workshop presented at AG Bell Association biennial convention, St.
Rhoades, E. A., & Powell, K. (under review). Developmental AVT: An early intervention program for
children 0-3. Washington, DC: AG Bell Association.
Robertson, I. (1999). Mind sculpture. London: Bantam Press.
Sharma, A., Dorman, M. F., & Spahr, A. J. (2002). A sensitive period for the development of the central
auditory system in children with cochlear implants: Implications for age of implantation. Ear &
Hearing, 23(6), 532-539.
Sindrey, D. (2003). Cochlear implant compass cards. Retrieved June 10, 2004, from
Smith, S., Goffman, L., & Stark, R. (1995). Speech motor development. Seminars in Speech & Language,
16, 87-98.
Stout, G. G., & Windle, J. V. E. (2001) Developmental approach to successful listening-II. Englewood,
CO: Resource Point.
Tye-Murray, N. (1993). Communication training for children and teenagers: Speech, listening,
speechreading, and using repair strategies. Austin TX: Pro-Ed.
Wayner, D. S., & Abrahamson, J. E. (2000). Better communication and hearing aids: A guide to hearing
aid use. Austin, TX: Hear Again.
Webster, D. (1995). Neuroscience of communication. San Diego: CA: Singular Publishing Group.
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