Learning how to listen while coming of age - Auditory Verbal Trainingкод для вставки
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 oneвЂџs 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 activities. Analysis of each studentвЂџs communicative interactive style is warranted. How persistent are the studentвЂџs 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 вЂњWhat?вЂќ 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 studentвЂџs 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 studentвЂџs 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 studentвЂџs speech perception and production can encompass both synthetic and analytic strategies, it is imperative that all activities be auditorybased. As the studentвЂџs 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 clinicianвЂџs 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 вЂћwithin earshotвЂџ in fairly quiet environments. The clinician should be seated next to the studentвЂџs implanted side, so that speech is presented within close proximity вЂ“ a distance of no more than 6-12 inches from the childвЂџs processor microphone. Whether or not a вЂћspeech hoopвЂџ or вЂћhand cueвЂџ 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 вЂћauditory sandwichвЂџ 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 childвЂџs benefit. Auditory repetitions neurologically set up the brain to understand what has been heard. Putting the speech signal вЂћback into hearingвЂџ 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 http://www.auditoryverbaltraining.com/websites.htm. 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 вЂњa cup of coffeeвЂќ like вЂњacuppacoffee.вЂќ 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. вЂњAli Baba and the forty thievesвЂќ is one such Think-Say-Do game. The student must first learn to chant the words вЂњAli Baba and the forty thievesвЂќ 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 вЂ“ 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 clinicianвЂџs auditory-based language. Still another Think-Say-Do activity for the student who needs to develop internal sense of rhythm is the popular preschool вЂњOne potato, two potatoвЂќ means of choosing who goes first. The student learns to elongate the vowel production of вЂћfourвЂџ and вЂћmoreвЂџ so that its rhythm is more or less synchronized with the movement of one cupped hand over another personвЂџs cupped hand or oneвЂџs 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 studentвЂџs 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: п‚· Increased speech perception skills п‚· Improved speech production, particularly in voice quality and suprasegmental features п‚· Better knowledge and use of language, particularly in morphological markers п‚· Improved self-management and coping strategies п‚· Greater ease in academic learning п‚· Possible usage of telephones without text п‚· Overall greater ease in daily living References 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 http://www.nature.com/nsu/990429/990429-2.html Hull, R. H. (1992). Aural rehabilitation: Serving children and adults. San Diego, CA: Singular Publishing. Janata, P., & Grafton, S. T. (2003). 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