"What is An Auditory Verbal Therapist?" - A Real Conversation Starter!

Today’s blog is written by  Elizabeth Rosenzweig MS CCC-SLP LSLS Cert. AVTwho is a speech language pathologist and a certified auditory verbal therapist in private practice. You can read more of her work at http://auditoryverbaltherapy.net

Elizabeth answers many of the same questions that I am frequently asked about Auditory Verbal Therapy and Hearing Loss. So, rather than reinventing the wheel...

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Elizabeth writes, "When you meet someone new, one of the first questions we tend to ask is, “What do you do?”  When I tell people that I teach children with hearing loss to listen and speak, it’s a real conversation starter.  Here are some of my most frequently asked questions about hearing loss, hearing technology, and Auditory Verbal Therapy.  What are yours?

What do you do?
I’m a Listening and Spoken Language Specialist, Certified Auditory Verbal Therapist.  The LSLS Cert. AVT designation means that I’m a speech-language pathologist* who has training above and beyond basic SLP certification specializing in guiding and coaching parents and caregivers to teach children with hearing loss to listen and speak without the use of sign language.  Here is more information about the Principles of Auditory Verbal Therapy.
*Members of other speech and hearing science-related professions (audiologists, teachers of the deaf) can also apply for LSLS certification.  I just happen to be an SLP by training.

So… you teach lipreading?
No, I don’t teach lipreading.  Here’s why.

So… you use sign language?
No.  The families I serve have chosen listening and spoken language for their children’s communication mode.  In fact, more than 85% of parents of children with hearing loss choose for their children to learn to listen and talk (Brown, 2006).  Oral communication gives their children access to the broader world, independence, improved literacy and phonological awareness, and even the ability to learn to communicate orally in more than one spoken language.  Learning to listen means a person with hearing loss — even profound hearing loss — can enjoy music, learn to use the telephone, and understand speech without visual cues.

What causes that [hearing loss]?
There are many different reasons that a person could be deaf or hard of hearing.  Some hearing loss is genetic — it can occur on its own or be part of a larger syndrome that causes other symptoms as well.  (For example, Connexin 26 deafness is caused by a mutation of the GJB2 protein which effects the hair cells of the inner ear but causes no other issues, while Usher Syndrome causes hearing loss but is also associated with vision loss).  Other hearing loss is the result of illness, injury, or age (age-related hearing loss is called presbycusis and is a natural part of the aging process).  There are genetic tests available to determine the cause of hearing loss, but remember that even if the genetic testing does not determine a cause for your/your child’s hearing loss, that does not necessarily mean it is not genetic in nature, just that we have not yet identified that particular genetic variant.  While we are often able to identify the cause of hearing loss, there are times that the cause is idiopathic (basically, medical speak for “we don’t know”).

But how do you teach a deaf person to listen if they can’t hear?
Access to hearing is crucial for learning to listen and speak naturally.  We [people with typical hearing] learned to talk because we spent our first months of life (even in utero, starting 20 weeks before we were born!) listening to the sounds of language around us.  Helping children with hearing loss gain access to sound is the first critical component of our task if we want to help them learn to talk as well.  This is why it is so, so important for people with hearing loss to be fitted immediately with the appropriate technology (hearing aids, Baha, or cochlear implant, depending on their level and type of hearing loss).  Unlike glasses, though, you don’t just put the hearing device on and your hearing issue is suddenly corrected.  It takes time and therapy to train the brain to listen.  It’s all about the brain.  

How old are the children you work with?
Thanks to newborn hearing screening, the majority of the children on my caseload were identified with hearing loss at birth.  Because I serve families from around the world, though, where newborn hearing screening may not be possible, I do have some children whose parents only discovered their hearing loss as toddlers when they were not meeting the expected speech, language, and listening milestones.  Other children on my caseload were born with hearing but lost it as a result of illness or injury.  I also work with teens and adults — either those who have had hearing loss their whole lives or those who lost their hearing after learning language and are looking to get back up to speed with new hearing technology (a hearing aid, Baha, or cochlear implant).

They’re identified at birth?  How can you tell that a baby can’t hear?
Newborn hearing screening is done one of two ways, either ABR (Auditory Brainstem Response) or OAE (OtoAcoustic Emissions) testing.  Both of these tests measure physiological responses to sound stimuli that do not require the baby to do anything to respond.  By measuring the brain’s response to sound (ABR) or the natural sounds emitted by a typically functioning ear (OAE — and yes, your ear is emitting sounds, even if you can’t hear them!), we can determine whether or not an infant (or any other unresponsive patient) is in need of further hearing testing.

But how do you do therapy with a child that young?
Early intervention is the key to success for children with hearing loss.  Here’s why.  The bulk of my work focuses on guiding and coaching the parents, supercharging their interactions with their child to help them facilitate the growth of language and listening skills from the very start.  If the child sleeps through the entire session, the parents and I are still learning together.  I just love working with infants and young children and their parents, helping them to build the foundation for a lifetime and language and listening success!

How do you work with clients around the world?
I use videoconference technology to provide teletherapy services to clients from all over the globe.  It’s like Skype or FaceTime, but more advanced to be compliant with HIPPA and other patient-privacy laws.  Curious about what atypical teletherapy session looks like or the benefits of teletherapy?  Check out my Teletherapy FAQs!

How do you do therapy without being physically present?
Many people think that “speech therapy” involves hands-on treatment (put your lips here, but your tongue here, etc.).  Auditory Verbal Therapy focuses on learning to listen and talk using a developmental, not remedial, approach.  My job is to coach the parents in how to infuse everyday activities and interactions with opportunities for listening, language, speech, and cognitive growth.  Not being present for teletherapy can actually be an advantage over in-person treatment because I can’t jump in.  I have to empower the parents to be their children’s first and best teachers, and that is key!  One hour of therapy a week is not enough.  For children to truly succeed, parents need to have the skills and confidence to implement AV techniques throughout the week.

How long does this therapy take?
There are many factors that affect a person’s outcome with a cochlear implant.  Let’s take a child who is identified early, fitted with appropriate technology, and has access to a Listening and Spoken Language Specialist and strong family support and commitment to the AV lifestyle.  For the children like this on my caseload, they usually don’t need me by the time they are 3-5 years old.  Basically, if everything goes well, they’re reading to mainstream from day one of preschool or kindergarten, with age-appropriate skills and minimal support.  For other children, perhaps those identified later or who have additional disabilities, progress may be slower and the timeline extended.  For teens and adults, therapy usually is shorter-term in nature, focused on building specific skills or re-learning how to hear with a new device.
Success is not an accident.  It takes lots of hard work, but incredible results are achievable.

What’s the difference between a cochlear implant and a hearing aid?
Here’s my simple explanation on hearing loss and hearing technology:
Sensorineural hearing loss (sometimes called “nerve deafness”) occurs when the cilia (hair cells) of the inner ear (the cochlea) do not function properly.  In an undamaged ear, the pressure from sound waves goes into your pinna (the outer ear, the part you can see), makes the eardrum move back and forth, is passed along the small bones of the middle ear (the smallest bones in your body!), and then transfers to the middle ear, where those sound waves cause actual waves in the fluid-filled cochlea.  The waves of fluid cause the hair cells to move.  This sets off a beautiful chemical chain reaction, which ultimately causes stimulation of the auditory nerve (cranial nerve VIII), which sends the sensation of “sound” to the brain.  The hair cells in the cochlea are tonotopically arranged, meaning that each region corresponds to different tones, going from high frequency sounds at the basal end to low frequency sounds at the apex of the cochlea, which looks like a snail shell.  Think of a piano keyboard that has been rolled into a spiral, except that the keys go from high to low, unlike a regular piano.
A hearing aid simply pushes more (louder) sound into this system.  If the sound is louder, it makes bigger waves in the cochlear fluid and stimulates those hair cells to say, “I heard that!”  It’s pushing more sound through the damaged system.  For some peoples’ degree of hearing loss, a hearing aid is enough to provide access to the full spectrum of speech sounds.
A cochlear implant replaces the damaged system altogether, and works for patients when a hearing aid is not enough to give adequate access to sound.  A cochlear implant consists of an internal electrode array (like a wire with various electrodes, points of contact, that is threaded through the cochlea to take the place of the damaged hair cells), and an external processor.  Sound goes into the CI microphone, then the processor (think of it as the “brain” of the CI) says, “Okay, to replicate this natural sound coming in with our electrical system, we need to stimulate electrodes #1, #5, and #12 in this order, in this pattern, at this rate.”  That message travels up the wire to the magnet/headpiece/coil on the outside of the CI users’s head, and FM waves transmit that information to the internal implant.  The proper electrodes of the internal array in the cochlea) are fired, and this message stimulates the auditory nerve, and the brain hears.
This is all a very simplified explanation of an exquisite process, but I think it gives enough information for a layperson to have a good working knowledge of the system — not too simple (so it seems like magic), not too complex (so it seems like mystery).

Can everyone benefit from a cochlear implant?
For some people with hearing loss, a hearing aid is enough to give them access to sound needed for brain development and the development of speech, language, and listening skills.  When a hearing aid is not providing enough access, it’s time to consider a cochlear implant.  In almost all cases of sensorineural deafness that is severe-profound (and we’re even creeping up to moderate loss in the case of borderline candidates), the patient can benefit from a cochlear implant.  Cases where a person who has sensorineural hearing loss severe enough to need a CI but cannot have one would include: lack of a cochlea (a very rare anatomical anomaly), lack of an auditory nerve (also very rare, in which case the person would be more of a candidate for an ABI, Auditory Brainstem Implant), ossified cochlea (for example, someone who had had meningitis years ago, and the cochlea has ossified [basically, "turned to bone"] to the extent that an electrode array cannot be put in), or other health conditions that preclude surgery.
There are also people who have conductive, not sensorineural hearing loss.  Here, the issue is not with the hair cells of the cochlea but with the outer or middle ear.  The cochlea works, we just can’t get the sound in.  These people benefit from bone conduction devices, like the Baha (or, in some cases, a traditional hearing aid).
HERE is more information on the cochlear implant process.

How much does that cost?
There is no set “off the shelf” price for a cochlear implant.  The cost varies based on a number of factors: the insurance system (does the patient have private insurance or do they live in a country with nationalized healthcare?), the surgeon and hospital fees, etc.  Most nationalized healthcare systems do include cochlear implants in their coverage.  In the United States, cochlear implants are covered by most private insurers as well as Medicare and Medicaid.  Unfortunately, coverage for hearing aids seems to lag behind, and though some families are able to receive hearing aids through early intervention or
See these articles for information on how to successfully argue for cochlear implant surgery or processor upgrades.  You can also find more information on sources of funding for hearing technology and sources of funding for auditory verbal therapy.

Is it as good as real hearing?  What does it sound like to them?
Asking what a cochlear implant sounds like to a person with hearing loss is like asking, “What does red look like to you?”  We are all limited by our own perceptions, and any simulation that we hear is just that: a simulation, based on our best knowledge of how the device’s algorithm processes sound, and then re-filtered through our own ears and brain as the listener.  This is not to say, however, that hearing loss simulations are inaccurate (learn more about why this is so, and how to understand hearing loss research, HERE).  We hear as well as we speak, and the fact that cochlear implant users are able to achieve very natural-sounding speech shows the remarkable capability of the brain to take electronic sounds and make them into clear, usable hearing.  For more on how hearing loss sounds, see this article.
Audiological results show that it is very possible for a person with hearing loss (who is appropriately amplified and has received good listening and spoken language instruction), to have hearing thresholds from 15-20dB across the board to 6000Hz and speech discrimination scores (in quiet and loud speech and speech in noise) in the 90% range.  This is comparable to how someone with unimpaired hearing might score.  Of course, even thousands of dollars of the best hearing equipment available cannot match the priceless gift of natural hearing, but in terms of actual results in practice, people with CIs and HAs can do remarkably well.  Why?  The brain is incredible.  

Does it work?
Again, the outcomes literally speak for themselves.  Decades of research on the outcomes of children with cochlear implants and/or those raised with Auditory Verbal Therapy show that, by and large, these children are learning to listen, talk, and read at levels commensurate with their hearing peers.  They are thriving in the mainstream, attending college, gainfully employed, and living lives that are as “normal” as anyone else.  For a great overview of research on this topic, see this collection from Utah State University.

How do the children do socially?
Social competence is often predicated on language success.  If you have the language and listening skills to keep up with your peers, socialization will be that much easier.  All children go through bumps in their development, butresearch shows us that children with cochlear implants generally report levels of self-esteem comparable to their hearing peers. 

How well do they hear music?
When cochlear implants were first developed, the external device was called a “speech processor,” not a “sound processor” like they are sometimes called today.  Why?  In the beginning, just the thought that a profoundly deaf person would be able to hear speech seemed too fantastic for words.  If that could be achieved, any access to additional sounds would just be icing on the cake.  Speech — and the communicative independence that came with it — was the goal.  Now, cochlear implant users can hear speech, music, and more!  Though cochlear implant users’ enjoyment of music varies (as does typically hearing peoples’, I might add), research shows us that cochlear implant users do have the capability to hear the difference between a wide range of pitches, and that practice and exposure can significantly increase CI users’ music enjoyment.  People with hearing loss who have good amplification and a strong AV foundation can even learn to play an instrument, participate in a choir, or take dance lessons.  HERE is more information on the latest research on CI/HA users and music.

How well do they hear in noise?
Hearing in noise can be tricky for anyone, but even more so for a person with hearing loss.  Our brains are trained to pick up the important signal (the person talking to us) and filter out the rest (the background noise), while still being attentive to certain sounds in the environment (a siren, an oncoming car, or someone calling our name from across the room).  It’s pretty impressive!  If a person with hearing loss has not had that auditory experience (and remember, this experience starts before you even take your first breath), it’s tough!  Auditory training, combined with the ability to today’s hearing technology to use a “computer brain” to identify and filter out background noise, can help a lot.  So can adaptive technology like FM and soundfield systems, and smart communication techniques.

Can people with hearing loss drive a car?  Talk on the phone?  Go to college?  Get married?  Listen to music on an iPod?  Learn a foreign language?  Play sports?

These questions may sound silly, but remember, most people have little to no everyday interaction with people with hearing loss.  The answers to all of these questions?  YES!
Yes, people with hearing loss can drive a car.  Yes, they can talk on the phone.  Yes, they can go to college (check out the Ultimate College Guide for Students with Hearing Loss for more info and tips!).  Yes, they can listen to music on an iPod (often linking it right to their hearing device, or, with even newer technology, streaming via bluetooth!).  Yes, people with hearing loss get married (to partners with and without hearing loss, read some stories HERE).  Yes, people with hearing loss can learn multiple oral languages.  Yes, people with hearing loss can play sports.  So much is possible!"