Monday, March 30, 2015

April Fools- Listening, Language and Learning

Looking for ideas for April Fools fun for listening, language and learning? 
Humor is a great way to target spoken language, social skills and more.

Sunday, March 22, 2015

Coaching Parents to Use Natural Experiences for Listening, Language and Learning

Today's post is written by Ellie White, M.S., M.Ed., CED and

 Dorie Noll, MSDE, CED, LSLS Cert. AVEd

This article is simple yet full of wisdom regarding coaching parents in meaningful strategies for developing listening and spoken language for their child with hearing loss during natural, regular and common experiences including daily routines.

Great article - Way to go Dorie! 

I met Dorie Noll when we volunteered together in Vietnam with the Global Foundation for Children with Hearing Loss in July of 2014.

Recently, I was fortunate to present at the
10th Annual 2015 EDHI Early Detection of Hearing Loss & Intervention Day
in Chicago on March 20, 2015. 

Just a few days earlier this article was published and I highly recommended 
it as a "Must Read" to all those in attendance.

This article can be found in the Volta Voices Magazine.

Keeping It Real

Coaching Parents to Use Natural Experiences

 for Learning

by Ellie White, M.S., M.Ed., CED, and Dorie Noll, MSDE, CED, LSLS Cert. AVEd

Listening and spoken language professionals who deliver services to young children with hearing loss and their families—such as early intervention providers, speech-language pathologists, teachers of the deaf and hard of hearing, and Listening and Spoken Language Specialists (LSLS®)—have limited, precious time each week or month to do so. They are charged with using each visit or session to prepare those caregivers to take on a task that is unfamiliar to most people: teaching listening and spoken language skills throughout the day to a child with hearing loss. These professionals must use the limited time during visits as efficiently as possible to maximize the caregivers’ potential at teaching these skills to their child between visits.

Caregivers are faced with challenges and demands on their time no matter what. Moreover, caregivers who must explicitly teach a child with hearing loss to listen and talk have even more to accomplish in a day. The most efficient and effective approach to coaching caregivers on how to do this is to teach them strategies for improving their child’s listening and spoken language during natural, regular and common experiences, including daily routines. This allows caregivers to accomplish their daily caregiving duties while using those same activities to teach spoken language skills.

Get the Basics: Learn the Family’s Daily Routines

keeping it real baby feedingProfessionals must first help parents identify the language their child needs to learn, based on their specific routines, in order to communicate successfully in their home environment. This begins with the first session, during which the professional and the caregivers talk through the child’s routines. Caregivers identify parts of the day which are successful and other times that are a struggle. Sometimes, difficult parts of the day can be improved by focusing on the language the child needs to successfully participate in that routine. By focusing on the language surrounding daily routines, the child gains valuable skills that will help him/her communicate with his/her family, rather than learning a specified set of vocabulary words associated with a particular toy or game. This allows for more practice, embedded in routines that happen naturally and regularly, and provides the child with functional tools to communicate.


One daily routine that can easily be enhanced with language development strategies is diapering. This repetitive activity performed multiple times per day provides ample opportunity for the practice of meaningful language as well as face-to-face interaction from an ideal distance for listening. Optimally, diapering should occur in a quiet environment with minimal background noise. The caregiver can take a little extra time to narrate what she/he is doing as she/he does it.

“It’s time to change your diaper. Let’s walk over there to the changing table. I’m going to lay you down right here on the changing table. Oh, look at these cute little feet. I’m going to kiss those feet. Let’s unzip your jammies. Down, down, down it goes. Now let’s take this foot out – one kiss for this foot. And then let’s take this foot out – one kiss for this foot. Let’s take off this wet diaper. It’s all wet. I’m going to throw it away. Let’s get the wipes. Pull! I got a wipe. Feel the wipe. It’s cold. Brr, the wipes are cold! Okay, let’s clean you up. There we go. Now we need a new, clean diaper. Bottoms up! Time to put your feet back in your jammies. One foot. Two feet. Zip, zip, zip. Zip your jammies. Now you have a nice clean diaper and we’re all done! How about a hug?”

Diapering also provides lots of opportunities to talk about body parts, items of clothing, or to play peek-a-boo or a tickle game. The caregiver can hang a small mirror on the wall next to the changing table and incorporate a few moments of mirror play. This simple activity can be enhanced to create a warm, language-rich interaction between caregiver and child, rather than a chore that must be rushed through many times a day.


Feeding is another repetitive routine that can easily be enhanced to incorporate listening and spoken language strategies with an infant. As with diapering, the professional can encourage caregivers to feed their baby in a quiet environment, with minimal background noise. Cradling the baby in the arms creates an optimal distance for listening and meaningful interaction, whether breastfeeding or bottle feeding. By taking the time to interact warmly with their baby, caregivers are helping to create a secure attachment as well as a motivating time for listening.

“Oh, sweet baby, you are really crying! Are you hungry? I hear you! Here it is. Here’s your bottle! Mmm, there you go. It’s yummy! That’s better. Now your belly feels much better!”

During feedings, the caregiver can sing songs, talk about body parts, or just speak softly and warmly about the day. Using a standard cradle hold to feed a baby is very natural, but can be tricky for a baby with hearing aids because of potential feedback. By simply altering the baby’s position from a standard cradle hold to a football hold, the caregiver decreases the potential for feedback and can be confident the baby is prepared for a wonderful listening opportunity.

Out and About

Busy caregivers can even incorporate strategies while running errands to create meaningful listening and language experiences for their infants or toddlers. Putting the infant carrier or the toddler in the grocery cart, for example, is a good face-to-face interaction that can help minimize the distractions of a noisy environment at the grocery store. Professionals should encourage the caregiver to use self-talk as he/she chooses which apples to buy (“I wonder which apples I should get. I like the green apples, but the red apples are on sale. I think I’ll get the red apples today.”), or narration as they walk down the aisles and look for all of the items on their grocery list (“OK, we have the milk, the bread and the eggs. Next, we need to get cheese. Where is the cheese? Oh, here it is.”). These opportunities add to the baby’s listening and language exposure while allowing caregivers to accomplish the tasks of a busy day.


keeping it real baby with blocksPlaytime is an important routine in which caregivers can enhance listening and language. For an infant, this may mean simply holding the baby face-to-face, without obscuring the hearing technology, and singing or talking to him/her. Caregivers can get down on the floor next to the baby and talk to him/her about the toys he/she is batting or activate a musical toy while cuing the infant to listen. Reading books is a valuable experience for every child, and caregivers can learn the value of reading books, using a rhythm while reading aloud and just talking about the pictures.

Infants and babies benefit from time spent every day interacting directly with their caregivers during play. Caregivers can use parallel talk to provide the valuable language of play. For example, “I see you are building a tower. I see a blue block, a red block and a yellow block. Up, up, up, dowwwwn! Uh oh! You knocked them down!” Caregivers can use language to help the child initiate play (“Let’s ask Daddy. Daddy, do you want to play?”), ask for help (“Oh no! You can’t get the lid off of the box. Do you need help? You can say, ‘help me.’”), and appropriately negotiate play (“Oh, do you want a turn? You can say, ‘my turn.’”).

Snack Time

Another way to enhance familiar routines is to teach the caregiver to make a snack together with the child. Caregivers may not realize how much language can be incorporated into this routine by simply extending it. Rather than giving the child the snack completely prepared, for example, the caregiver can cut up fruit with the child, for example, and use repetitive language such as “cut,” “take a bite,” “mmm, yummy” and “more.” If the child is eating crackers, the caregiver can prompt the child to ask for them, and then only give him/her a few at a time, so he/she has lots of opportunities to ask for “more crackers.”

Additionally, the professional can coach the caregiver to create a meaningful listening experience by listening for the microwave to beep indicating that the oatmeal is ready, and then encourage talking by expecting his/her child to verbally request “more” when he/she wants another bite. These simple extensions can turn snack and meal times into meaningful listening and language experiences, during which the practitioner can coach the caregiver to incorporate strategies such as wait time, withholding, narrating and sabotage. Meal time is usually very appealing for a young child, so caregivers can capitalize on that natural interest to create a motivating reason for communicating. Caregivers can be coached to incorporate sabotage by pretending to pour juice without taking the lid off so the child has to request that the lid be removed, withholding by only giving the child two or three crackers at a time so he/she has to repeatedly request more, narrating by describing the food preparation or talking about what the child is eating, and wait time by asking the child a question and waiting patiently and expectantly for a response.

Household Chores

Caregivers can also be coached to use simple household chores to provide fun, meaningful language opportunities. By taking a little extra time to complete these chores, the caregiver can enrich the language associated with the chores in addition to taking advantage of a toddler’s natural desire to “help.”

For example, a caregiver can provide a toddler with a damp paper towel to wipe down the table or a dry one to help with dusting; or fill a squirt bottle with water and teach the child to “squeeze” and “wipe” the windows. The child can help the caregiver match socks, roll them into a ball, and throw them into the laundry basket, working on color words and sorting, sequencing (first, then), as well as simple vocabulary like “sock” and “throw.” Sorting laundry can become an auditory exercise as simple as “hand me the pants” or as complex as listening for two critical elements: “Give me the red shirt.” Caregivers can turn washing dishes into an engaging sensory experience, during which one can build vocabulary by naming items, work on counting and color words, and practice adjectives such as “hot,” “cold,” “wet” or “dry.”

Using Daily Routines

The most natural experiences a child has each day are based on the family’s daily routines. Daily routines are the single most important resource for activities to encourage listening and language development. After all, young children should be able to talk about the activities of their daily lives. Busy caregivers might go through these routines, such as eating breakfast or getting dressed, with the intention of accomplishing the task at hand quickly and efficiently rather than teaching the language.

Professionals can point out that these daily routines are big opportunities for language development with the child. During sessions, professionals can promote listening and language of daily routines by coaching caregivers through the activities. The practitioner can demonstrate how to talk about what the child is experiencing, label objects and incorporate songs while performing the task of the activity. Caregivers can practice enriching the language of these routines, while encouraging the child to listen, imitate and respond. Everyday routines provide ample opportunities for meaningful repetition and this repetition reinforces the language of daily activities often and naturally. Additionally, these daily activities are familiar to caregivers, so they feel more comfortable talking about what they are doing than they might with less familiar activities.

Avoiding the Toy Bag

Many professionals plan various craft activities and games to motivate young children to improve their language during home visits. However, the language of crafts or games that are only played during sessions is less useful for the caregiver and child on a regular basis, and therefore less “bang for the buck.” Materials brought in to be used in the session but not left with the caregivers only allow for infrequent and potentially less useful language practice. Caregivers may learn from their listening and spoken language professional strategies for using certain games and toys for language development, yet may not be able to generalize those strategies with their own toys or during routine activities. If the professional brings toys for visits and then leaves them for parents to use between visits, this allows for more practice time. Yet, this means caregivers must set aside additional time during their already busy day to play with these specific toys that they might not otherwise do. They may also feel less comfortable with the strategies or language associated with toys or games that don’t belong to them. It makes sense for children to understand and use the language of their daily routines and activities because that will be most meaningful to them. Helping caregivers enrich this language is the most efficient use of the professional’s limited time and resources.

Ultimately, practitioners work with parents through active and timely coaching to teach them how to use natural, everyday activities and proven techniques to prepare their infant with hearing loss to become a 3- to 4-year-old chatterbox whose daily life is filled with singing, reading, conversation and games with peers regardless of hearing ability in a variety of acoustic environments, so that children with hearing loss are ready for a mainstream school environment, self-advocacy and wholehearted participation in their community of choice. 
Ellie White, M.S., M.Ed., CED, is a teacher of the deaf at Central Institute for the Deaf in the pre-kindergarten/kindergarten department as well as a curriculum facilitator. She also serves as practicum coordinator and lecturer at Washington University’s School of Medicine Program in Audiology and Communication Sciences. White holds teaching certification in the state of Missouri in the areas of Deaf and Hearing Impaired and Early Childhood Education, as well as Missouri state principal certification. She holds professional certification from the Council on Education of the Deaf. White has published a number of articles and assessment tools related to instructing children who are deaf and hard of hearing. She can be reached at

Dorie Noll, MSDE, CED, LSLS Cert. AVEd, is a parent educator in the Central Institute for the Deaf (CID) Joanne Parrish Knight Family Center. She also serves as lecturer at Washington University’s School of Medicine Program in Audiology and Communication Sciences. She has served as teacher in the CID Nursery Class, facilitated the CID Nursery Class program and provided early intervention services to families in the home. She holds teaching certification in the state of Missouri in Deaf and Hearing Impaired and is credentialed with the early intervention programs in both Missouri and Illinois. Noll is also a certified parent educator with the Parents as Teachers program in Missouri and holds professional certification from the Council on Education of the Deaf. Noll is the mother of a smart, successful, flourishing, 16-year-old son with profound hearing loss and a cochlear implant. She can be reached at

Saturday, March 21, 2015

The Power of One - EDHI Day 2015 in Illinois

Governor Bruce Rauner declared March 20th Early Hearing Detection & Intervention Day for Illinois. I was privileged to attend when friends and colleagues were honored and be the program presenter.
The beautiful d├ęcor centered on starfish, which seemed different in Chicago with the nearest ocean many miles away. Then, Carrie Balian, Coordinator of Guide By Your Side Of Illinois Hands & Voices shared the powerful Starfish Story and how each one of us  can make a difference. Do you know the story?

At times in our lives, we are all the old man, the young man, or the starfish.
Sometimes, as the old man, we don't see the purpose to actions.
Sometimes, as the young man, we persevere and make a difference.
And sometimes, we are the starfish who just need a little help."

Wednesday, March 18, 2015

Tri-Bond, Shamrocks and Auditory Association

mail ~ shoe ~ lunch 

What do these three words have in common?

Tribond is a game that gives you three words and you must tell how these are related.  

One of my Little Listeners made this one up for me. Here are her clues:

McDonald’s, A bank, A car wash.  The answer is they all have DRIVE THRUs!

TriBonds targets higher level thinking and auditory comprehension. Listen and by auditory association find the common link that joins three words. At first, they may seem to have nothing in common. This game of threes requires auditory processing, a good vocabulary or background knowledge and deductive reasoning. 

TriBonds can be relatively easy:
carrots ~celery ~ lettuce
Or much more challenging:
car tires ~ planets ~ crops

Depending on the age of your child you can buy the game - there is a kid's version or here some ways that you can use TriBonds: 

As a family come up with their own Tribonds. First,  come up with a common word and then try to find three words to go with it. 

  • Keep a list of TriBonds (or the cards from the game) nearby for those extra few minutes in the car, before dinner etc. 
  • Start a family listening and spoken language tradition with a "Daily TriBond."
  • Check out the Tribond website for their Daily Tribond.

Here are some (kid's) TriBonds that are all connected by a single word to get you started.    I know I should probably give the answers. But then what fun would that be?Reference:

  • book ~ cell ~ number
  • head ~ marching ~ aid
  • sauce ~ seed ~ core
  • camp ~ house ~ wild
  • town ~ work ~ base
  • board ~ out ~ house
  • work ~ rocky ~ rail
  • seat ~ fan ~ leather
  • house ~ day ~ lucky
  • rose ~ soup ~ dust
  • foot ~ snow ~ room
  • seat ~ box ~ pane
  • pad ~ trap ~ field
  • tug ~ motor ~ life
  • fall ~ fresh ~ bottle
  • plug ~ ring ~ phone
  • walk ~ game ~ diving
  • up, pack, switch
  • pig ~ light ~ fountain
  • brain ~ house ~ blue
  • snow ~ drain ~ sand
  • shelf ~ phone ~ mark
  • hard ~ top ~ sun
  • business ~ playing ~ index
  • mate ~ class ~ bath
  • chocolate ~ maid ~ carton
  • sea ~ egg ~ turtle
  • swing ~ spare ~ track
  • bell ~ mat ~ knob
  • sweat ~ tail ~polo
  • ache ~ band ~ board
  • house ~ fire ~ flash
  • bed ~ computer ~ bite
  • ground ~ house ~ double

Thursday, March 12, 2015

Illinois 10th Annual EHDI Day March 20, 2015

Register Today!

Join us on March 20th, 2015
 at the Chicago Hearing Society,
 2001 N. Clybourn
as we celebrate our 10th annual 
 Early Hearing Detection & Intervention Day!

To view the full size EHDI Day invitation with interactive links please click here!

To register to attend all or part of the day please go to

We have a full day planned – it’s something you don’t want to miss!

Auditory-Verbal Therapy - Evidence for the Effectiveness

Today's post is from Jane Madell, Editor of Hearing Health. Hearing & Kids @ Hearing Health & Technology Matters February 24, 2015. 

The post is written by  Dr. Dimity Dornan, the Executive Director and Founder of Hear and Say, an auditory verbal center in Brisbane, Australia

 Here is the link.

Auditory-Verbal Therapy has been shown to be effective for developing listening and spoken language for children with hearing loss (Dornan, et al., 2010). To maximize listening and spoken language development, children with hearing loss require optimal amplification in combination with specialized listening and spoken language early intervention. Amplification alone does not allow for optimal spoken language development (Wilkins & Ertmer, 2002).

In Auditory-Verbal Therapy, parents are valued members of the early intervention team. In partnership with the Auditory-Verbal Therapist, parents are guided and coached to facilitate their child’s spoken language development through listening.

Auditory-Verbal Therapy successfully develops the listening and spoken language of children with hearing loss by stimulating auditory brain development, enabling children to make meaning of what they hear and laying down neural pathways for speech and language development (AG Bell Academy for Listening and Spoken Language 2013; Chermak et al, 2007; Cole & Flexer, 2007). Learning through listening is the most effective way of developing spoken language, cognition and literacy skills (Cole & Flexer, 2007). Auditory-Verbal Therapy, with its foundation in teaching through listening, has been proven to be most effective in developing the spoken language and educational outcomes of children with hearing loss.

In Auditory-Verbal Therapy, parents are valued members of the early intervention team. In partnership with the Auditory-Verbal Therapist, parents are guided and coached to facilitate their child’s spoken language development through listening.

                               kids whispering

Research shows that children with hearing loss in an Auditory-Verbal Therapy program:

 • Graduated with no gap between their chronological and language ages and developed spoken language in line with normally hearing peers (Constantinescu, Dornan, Rushbrooke, Brown, McGovern, Close, Hickson & Waite, In review; Dornan, Hickson, Murdoch, & Houston, 2007, 2009; Dornan, Hickson, Murdoch, Houston, & Constantinescu, 2010; Fulcher, Purcell, Baker, & Munro, 2012; Hogan, Stoke, White, Tyszkiewicz, & Woolgar, 2008; Rhoades & Chisolm, 2000).
  • Made, on average, 12 months’ progress in 12 months for their spoken language development, which is in line with expectations for children with normal hearing (Dornan, Hickson, Murdoch, & Houston, 2007, 2009; Dornan, Hickson, Murdoch, Houston, & Constantinescu, 2010; Rhoades & Chisolm, 2000).
  • Progressed at the same rate for spoken language, self-esteem, reading and mathematics as a matched group of children with normal hearing (Dornan, Hickson, Murdoch, Houston, & Constantinescu, 2010).
  • Achieved age-appropriate spoken language as early as 6 months after amplification and around 12 months of age – when identified at birth and fitted with optimal amplification and enrolled in Auditory-Verbal Therapy before 12 months of age (Constantinescu, Waite, Dornan, Rushbrooke, Brown, Close, & McGovern, submitted).
  • Performed better for spoken language and listening than a matched group of children in an Auditory-Oral (listening and lip reading), or Bilingual-Bicultural program (AUSLAN and written English) by 3 years of cochlear implant use (Dettman, Wall, Constantinescu, & Dowell, 2013).
  • Achieved comparable social inclusion outcomes to normally hearing peers (Constantinescu, Phillips, Davis, Dornan, & Hogan, In review).
  • At 3 and 4 years of age, speech production results showed that
  • (1) All children produced single phonemes + clusters following typical developmental patterns.
    (2) All children had increased their inventory for consonant clusters from 3  to 4 years of age.
    (3) The number and type clusters produced were at least in the average range when compared to normative data.

AG Bell Academy for Listening and Spoken Language. (2013). The AG Bell Academy for Listening and Spoken Language. See (last checked 1 Jan 2013).
Chermak, G., Bellis, T., & Musiek, F. (2007). Neurobiology, cognitive science and intervention. In G. Chermak & F. Musiek (Eds.), Handbook of (central) auditory processing disorder: Vol. 2. Comprehensive intervention (pp. 3-28). San Diego, CA: Plural Publishing.
Cole, E., & Flexer, C. (2007). Children with hearing loss: Developing listening and talking birth to six. San Diego, CA: Plural Publishing.
Constantinescu, G., Phillips, R., Davis, A., Dornan, D., & Hogan, A. (In review). Benchmarking social inclusion for children with hearing loss in listening and spoken language early intervention.
Constantinescu, G., Waite, M., Dornan, D., Rushbrooke, E., Brown, J., Close, L., & McGovern, J. (In review). Outcomes of an Auditory-Verbal Therapy program for young children with hearing loss.
Dettman, S., Wall, E., Constantinescu, G., & Dowell, R. (2013). Communication outcomes for groups of children using cochlear implants enrolled in Auditory-Verbal, Aural-Oral, and Bilingual-Bicultural early intervention programs. Otology & Neurotology, 34, 451-459.
Dornan, D., Hickson, L., Murdoch, B., & Houston, T. (2007). Outcomes of an Auditory-Verbal program for children with hearing loss: A comparative study with a matched group of children with typical hearing. The Volta Review, 107, 37-54.
Dornan, D., Hickson, L., Murdoch, B., & Houston, T. (2009). Longitudinal study of speech and language for children with hearing loss in Auditory-Verbal Therapy programs. The Volta Review, 109, 61-85.
Dornan, D., Hickson, L., Murdoch, B., Houston, T., & Constantinescu, G. (2010). Is Auditory-Verbal Therapy effective for children with hearing loss? The Volta Review, 110, 361-387.
Fulcher, A., Purcell, A.A., Baker, E., & Munro, N. (2012). Listen up: Children with early identified hearing loss achieve age-appropriate speech/language outcomes by 3 years-of-age. International Journal of Pediatric Otorhinolaryngology, 76, 1785-1794.
Fulcher, A., Baker, E., Purcell, A., & Munro, N. (2014). Typical consonant cluster acquisition in auditory-verbal children with early-identified severe/profound hearing loss. International Journal of Speech-Language Pathology, 16(1), 69–81.
Hogan, S., Stoke, J., White, C., Tyszkiewicz, E., & Woolgar, A. (2008). An evaluation of AVT using rate of early language development as an outcome measure. Deafness and Education International, 10(3), 143-167.
Rhoades, E.A., & Chisolm, T.H. (2000). Global language progress with an Auditory-Verbal approach for children who are deaf and hard of hearing. The Volta Review, 102, 5-24.

Wilkins, M., & Ertmer, D. (2002). Introducing young children who are deaf or hard of hearing to spoken language: Child’s Voice, an Oral School. Language, Speech, and Hearing Services in Schools, 33(3), 198-204.

Wednesday, March 11, 2015

Global Foundation for Children with Hearing Loss - Vision and Purpose Video

I am humbled to have been part of the Global Foundation for Children with Hearing Loss​ team in Vietnam providing opportunities in this developing country for early identification of hearing loss, access to hearing technology and the support of trained professionals to help develop listening and spoken language.

Listen to Paige Stringer, the founder and executive director share the Global Foundation's vision and purpose based on her own experiences growing up with hearing loss in America.

Click this LINK

Tuesday, March 10, 2015

When—if ever—is a child who successfully uses bilateral hearing aids a candidate for cochlear implants? Hear Better? Never Say Never

Today's post can be found at: The ASHA Leader, March 2015, Vol. 20, 36-42 

Hearing aids provide excellent audibility for children with moderate-to-severe hearing loss, but for some children, the benefit of hearing aids is limited compared with what implants can provide. CIs have the potential to provide equal audibility for soft sounds across the entire speech frequency range, an achievement not always possible with hearing aids.

Courtesy of Advanced Bionics LLC

Nine-year-old Ethan was born with a bilateral moderate-to-severe sensorineural hearing loss and has worn behind-the-ear hearing aids since he was a few months old. He earns high grades in regular education, speaks intelligibly, and has age-appropriate speech and language scores. Though he generally perceives speech well, he struggles to discern novel words with high-frequency speech sounds, and shows significant difficulty hearing in noise. He also lacks the speech clarity of other children with similar hearing loss—his voice is loud, and his fricatives and affricates are distorted.

Even though Ethan’s hearing aids are helping, could a cochlear implant allow him even better access to sound, and make listening and talking easier for him?
Just five or 10 years ago, cochlear implants were thought to be suitable only for children with very severe or profound hearing loss. Because he is progressing with his hearing aids, Ethan would likely not have been considered a good candidate for implantation.
Today, he would.

The change is due not only to relaxed implant criteria, but also to the fact that children with CIs are functioning exceptionally well in difficult listening environments, meeting age-appropriate goals for speech, language and academics, and listening to more complex stimuli such as music. It is possible that in some cases, children with CIs may surpass the progress made by children with hearing aids. When testing and observation suggest that the benefits of a CI may be superior to the child’s current functional performance with well-fit hearing aids, that child would be considered for an implant.

However, parents of successful hearing-aid wearers may be reluctant to opt for CIs because of risks such as loss of residual hearing. I often hear: “She is doing OK with her hearing aids.” Despite the potential benefits of CIs, this concern is valid, and it is also well-established that the earlier CIs are implanted, the higher the chance for success. Therefore, implanting a child who already receives benefit from hearing aids may not seem to be a reasonable recommendation, unless there is a sudden change in hearing.
The question, therefore, for clinicians and parents of older children who use bilateral hearing aids may be, “Can the child function even better with a cochlear implant?”

Courtesy of Advanced Bionics LLC
Current candidacy

For children ages 2–17, the criteria for CIs include a severe-to-profound hearing loss and limited benefit from binaural amplification, according to ASHA policy documents. “Limited benefit” is demonstrated through performance with hearing aids in the sound booth using tones and word-recognition tasks presented in an auditory-only format. When children meet this criteria, the decision to implant may be easy at any age.
In many cases, however, older children with binaural amplification have benefitted from hearing aids for many years. They may have received auditory-based therapy and possess excellent speech and language skills. They often fall outside of the traditional candidacy criteria in performance on word-recognition tasks. Their success in that area may be due to excellent audibility with the hearing aids, familiarity with the task, and well-developed top-down processing that allows them to fill in the gaps.
In a quiet setting, these students may appear to function quite well. However, in comparison with children with CIs, students with severe hearing loss and hearing aids may be less able to detect sounds at all frequencies (especially high frequencies), may have limited access to soft conversational speech, may experience more difficulty listening in noisy environments, and may exert more listening effort to communicate in a mainstream environment. In my experience, this functional difference in performance between groups is often noted by parents and educators.

Could it be better?

The decision-making process is unique to each family. Ethan and his parents learned what the implant was, spoke with many children and adults with CIs about their experiences, and investigated surgeons. Ultimately, they decided to go forward with the procedure.
The initial transition can be a jolt. After implantation, at his initial CI stimulation in December 2014, Ethan said, “I can’t understand you! Can I put my hearing aid on?” Even though he was able to respond with just the implants, he disliked the sound—it was an emotional appointment. A week later, however, after using only his cochlear implant processor, he was able to understand speech with no visual cues. Today, his speech perception of novel words is excellent, his speech clarity has improved, and the volume of his voice has decreased. Ethan’s prognosis of being a successful CI user is excellent.

“It is only up from here for Ethan,” his mother says. “Pre-implant, if we were at a raucous family event, we would have to talk loudly and repeat his name to get his attention. Twenty-two days after Ethan’s surgery, on Christmas Eve in a small house of 30-plus people, I spoke his name in moderate voice from one room away, and heard him say, ‘Yeah?’ It hit us that he’d truly heard us. That moment was life-changing.”
Some families may opt for a second implant. Eight-year-old Farah is a bilateral CI user. The decision to implant her first ear was stressful, but clear-cut. Farah had worn bilateral behind-the-ear hearing aids successfully soon after birth. Her audiologist, speech-language pathologist, and parents began considering a CI when Farah was 4—they were concerned that although Farah had good access to speech and language, her abilities had plateaued. The choice was solidified following a gradual drop in Farah’s hearing that moved her from borderline to well within the CI candidacy range, and the family decided to pursue a CI for her first ear at 5.

This initial CI decision was straightforward, but the decision to implant the second ear was more complicated. Farah was extremely successful with her first CI and became a bimodal user, wearing both her speech processor and hearing aid during all waking moments. For her hearing-aid ear, she was a borderline candidate for a CI; she had a moderately severe to severe sensorineural hearing loss and her word recognition scores were high with the hearing aid. The family was concerned that pursuing a CI in this ear might sacrifice the residual hearing she had, leading to more difficulty hearing in the future.
Farah used an FM system, performed well academically, and was socially active in her mainstream elementary school. After two years of using the initial CI, Farah noticed she had more difficulty understanding soft speech and speech at a distance with the hearing aid, and that her overall ease of listening with the implant was significantly better than with the hearing aid.

Farah was considered a successful bimodal hearing aid user, but could she do better with a second implant? The team decided she could.
Farah received her second CI at 8, and immediately following activation, she completed open-set speech-recognition tasks, even though the sound was “funny.” Following three weeks of regular programming sessions and therapy focused on the “new” ear alone, she had improved word-recognition scores and was wearing and relying on her second implant regularly.

Courtesy of Advanced Bionics LLC
Why implant later?

Hearing aids provide excellent audibility for children with moderate-to-severe hearing loss, but for some children, the benefit of hearing aids is limited compared with what implants can provide. CIs have the potential to provide equal audibility for soft sounds across the entire speech frequency range, an achievement not always possible with hearing aids.
For many children, a CI results in better audibility of soft high-frequency sounds such as /f/ and /s/, which can affect speech perception, speech production and a child’s ability to perceive and use grammatical markers in running speech. Access to more sound also can mean enhanced bottom-up processing: Because the signal is clearer and more robust, students may need to rely less on top-down processing, leading to less listening effort and less “filling in the blanks,” and enhancing overall ease of listening.
Cochlear implants can provide equal audibility for soft sounds across the entire speech frequency range, an achievement not always possible with hearing aids.

Maximizing success

Implanting later in a child’s life results in new challenges. At older ages, children have more control over use and retention of a device and the environments in which they are listening. And because they have had hearing-aid experience, they will form immediate opinions regarding sound quality. As a result, it is crucial to establish a solid rehabilitation plan ahead of time with the child and family. The following supports will encourage acceptance and enhance success for the newly implanted ear.
  • Pre-surgical counseling and support. It is important that the family understands the risks of implanting—including the possible loss of residual hearing—and the possible benefits. Current surgical techniques facilitate preservation of residual hearing, but it is not guaranteed. Counseling on realistic expectations is also critical. Initially, sound through the implant may seem distorted, annoying and dissonant, and the child may resist wearing the CI because of the difference in sound quality. The family and the child need to understand that this is a normal part of the process and that perseverance is essential.
  • Strategic scheduling. It may be beneficial to schedule the cochlear implant surgery so that the initial stimulation is during the summer or a school vacation. This timing allows the school-age child to use the processor by itself for longer periods of time in environments that require fewer auditory demands.
  • A concrete retention plan. If given a choice, children may initially prefer use of the opposite ear (hearing aid or initial cochlear implant) alone. But from the day of the initial stimulation, the new CI should be worn all the time with the contralateral device added as the situation demands. During academically and socially demanding situations, both devices should be worn. This transition can be difficult for the parents to enforce—they need support from the team.
  • Audiologic rehabilitation. As soon as the new implant is activated, students must participate in audiologic rehabilitation to reinforce progress and build confidence. It is critical that the focus be on what the student is already able to do rather than on what the student is missing. The importance of building confidence—beginning at the initial stimulation—cannot be overstated. Because of their previous auditory experiences, this group may show rapid improvement in speech perception, but lag in confidence and acceptance with the new device.
  • Regular programming sessions and subsequent hearing aid adjustments. The audiologist and SLP should follow the child closely. To maximize CI performance and overall speech perception in the bimodal/bilateral condition, students require adjustments to their older device in conjunction with new CI programming.
  • Family support. In-clinic support from professionals and support from other families and children facilitate the transition to the CI.
It should be noted that CIs may not be the best option for many children and their families, espcially if they do not have a strong support system in place. For an older child to be successful, CI implantation requires extensive pre- and post-implant counseling, professional collaboration, realistic parental and child expectations, and appropriate post-implant audiologic rehabilitation.
Ethan and Farah were already excellent hearing-aid users, successful in a mainstream environment, and functioning well socially. The CI was considered because they were struggling more than their peers who use CIs. Functional testing in quiet and in noise, in addition to the audiogram and word-recognition testing, supported candidacy in these cases. Both families observed other students with CIs and indicated there was a noticeable difference in “ease of listening” in both quiet and difficult listening situations, compared with what their child experienced.

It is important for professionals working with children with hearing loss to understand that although speech perception and detection testing provide valuable information, for some students using hearing aids the question may be, “Can this child do even better?” When the answer is “yes,” it is not too late to recommend CIs.

American Speech-Language-Hearing Association. (2004). Cochlear implants [Technical Report].
American Academy of Audiology. (2015). Cochlear implants in children. Retrieved from
  • Kristin Vasil Dilaj, AuD, PhD, CCC-A, is an audiologist at The New England Center of Hearing Rehabilitation. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.
  • Jennifer Cox, AuD, CCC-A, is an audiologist at The New England Center of Hearing Rehabilitation.

  • © 2015 American Speech-Language-Hearing Association

Monday, March 2, 2015

Learning To Listen Sounds

This printable handout of the Learning to Listen Sounds can be found HERE on the John Tracy Clinic's blog with Ideas and Advice for Parents of Children with Hearing Loss. Similar information is available at many Auditory Verbal Therapy websites.

MARCH: Listening and Spoken Language Calendar

Here is a month's worth of language suggestions that you can incorporate into

AUDITORY VERBAL THERAPY activities with your child.

Click HERE to download your own printable copy.