An Auditory Approach: Focus on Children with Bilateral Cochlear Implants

This text-based course is a transcript of the live webinar.  Download supplemental course materials.

Donna Sorkin:  This is Donna Sorkin from Cochlear Americas.  I want to welcome everyone to HOPE Online, a program we started at Cochlear Americas to support educational professionals who work with children with cochlear implants.  We want to ensure that our children have the best possible outcomes with our technology.  This seminar is the 17^th in the series.   If you have missed some of those and would like to catch up, we have recorded and archived them so you can go back and take them at your convenience.  I encourage all of you who have just signed up for the first time or who have missed some of these, to go back and take a look at what you have missed. 

We are thrilled to have Nancy Caleffe-Schenck, who is a certified auditory verbal therapist in private practice in Colorado.  Nancy is also an audiologist and a teacher of the deaf.  She has a broad set of credentials in approaching this topic and in working with children with cochlear implants.  This is a very exciting topic as more and more families are seeking bilateral cochlear implantations for their children, but we are still learning the best way to serve these children.  Nancy has had a number of children who have gotten second implants.  She is the best possible person to provide this seminar today.  She is a consultant, author, lecturer, and trainer/mentor.  She has been a member of cochlear implant teams and she does a lot of work for us at Cochlear.  I am very happy to have Nancy with us today. 

Nancy Caleffe-Schenck:  I will begin spending some time establishing general practices for creating positive listening experiences for children who received a second implant.  We will go on to discuss the expected goals for each successive stage of auditory development.  Then we move on to the really exciting and fun part of the presentation which is talking about some therapy, school, and home activities for each stage.  Then we will spend a few minutes considering educational implications and the team approach when a child has two implants.  At the end, there will be a little time for questions and answers. 

General Practices for Creating Positive Listening Experiences

We ask the question, “Why are even discussing this?”  It is really simple.  We want the child to like his or her implants, and we do this by creating positive listening experiences.  The first thing we have to talk about is that we need to realize the differences in each child, family, and educational experience.  We also need to know that the child really needs to wear the new implant alone for a specified time each day.  Keep in mind that children tend to make faster progress with their second sequential implant if they practice listening with the new implant alone, than if they do not practice with the new implant alone.  We also want to build the child’s confidence with the new implant and sometimes a child does not even realize that he or she is actually hearing.  This is why confidence is so important.  We want to create success by following an auditory hierarchy and setting goals.  Auditory development is relatively predictable and there are several published auditory hierarchies.  Today I will only discuss one.  We will also want to partner with parents and professionals.  The way we do this is by creating an active partnership and especially communicating with the parents and professional’s goals, and the process by which we are achieving these goals. 

Toolbox Tips for Realizing Differences

First, I like to think of this as the “FAB LAW”.  This acronym stands for: Flexible, Ages, Behavior, Level of the child literally and figuratively, Advocate for the child, and the Whole child.

Be flexible:  We need to individualize and the way that we do that is by having a toolbox of toys nearby that help us to facilitate the child reaching the goals that we are working on.  We have to be flexible with the activity as long as we are clear on the goals.  It is like a road map.  If you know where you are going, there are many different ways to get there.  The different ways we get there are through activities, toys, and children’s literature. 

Consider ages:  We have the consider the child’s chronological age, hearing age, cochlear implant age with one and/or both of the implants, and we cannot talk too much about all of these activities without also talking about behavior.  We need to expect the same behavior as we would with typical children.  This starts by the child learning the “listening routine.”  This starts with the child getting ready to listen, getting in the listening position, and then waiting for the toy.  The way we build the trust and confidence of the child is that he learns that he will get his turn once his listens and connects that to spoken language.  That also helps to eliminate any grabbing behavior.  Eventually we want to expect the child to listen while he is engaged in other activities. 

Going on to the levels of the child, think of this both literally and figuratively.  Literally target your level for establishing goals by working at 80% success rate.  Also keep in mind that when you are setting goals, remember that children who learn to listen with a first implant tend to make faster progress with the second implant than they did with the first.  Figuratively, when we talk about levels, this is pretty simple.  You need to view what you are doing from the eyes and the ears of the child.  The child should always finish the activity feeling happy and good about himself.  I tend to work on the more challenging goals early in the session or day and then finish with what I call a confidence builder, something the child is comfortable with, or something that may seem a little more relaxing. 

The “A” in “FAB LAW” is for advocate.  We need to be an advocate for the child.  The way we do this is by coaching parents on how to be an advocate for their child. 

Let’s look at the whole child.  Consider that in terms of the language used at home, family dynamics, things like family values, and pragmatics.  Do not forget about sensorimotor development and areas such as that.  Be sure to refer to related professionals if that is indicated.  When we are talking about children with bilateral implants, this is especially important because we may need to make some changes on the child’s IEP after the child gets his second implant.  This is discussed in another presentation and I will not go into detail with that now.

Wear It to Know It

Wearing the new implants alone in a structured and informal setting will really build the child’s confidence.  We also want to incorporate binaural listening activities so that the two signals are integrated.   This often happens naturally for the child.  If you are working with a child and you are feeling that there is some issue with the integration of both of the implants and how the child perceives that signal, here are some suggestions.  First of all you should encourage the parents to have the child enjoy real world activities where there are opportunities for localization such as attending a baseball game where there are a lot of sounds and voices going on behind him.  This is a great time for a child to practice localization with two implants on.  Another opportunity is listening on the playground, listening for his friend’s voices, listening for the teacher’s voice, and so forth.  Another strategy would be listening specifically with background noise present such as carrying on conversations in restaurants, maybe taking your therapy session to the gymnasium or at home, turning music on. 

Another activity would be to have the child specifically attend to quiet sounds, voices, and whispers to really appreciate the binaural summation that goes on with two implants.  If you have a situation in a library where you could go and practice this and not disturb other people, where the child is practicing listening and also quietly conversing, that would be good.   You should also have the child turn on stereo music or try listening to TV with a stereo signal.  Another idea is to compare and contrast listening with one versus two implants.  This is really so the child gets to realize the advantage of having two implants.  Oftentimes children just take this so naturally.  Finally you should discuss the subjective benefits, for example that the sound is fuller, less stressful having two implants, or they are having more fun with friends.  These are some of the kinds of feedback that I got from parents and children to whom I sent a questionnaire. 

How long should the child wear the new implant alone?  Children should do this each day at least 1 hour per day in spoken language environments.  Strive for 2 hours or longer or all day long all the time if possible.  You have to realize and have to make it clear especially with older children, that it does not count if this time being spent is when the child is doing instant messaging or working on computer games.  Over time I like to continue with the new implant alone each day for the length of time I have established for them until the child’s speech perception scores are close to those of the first implant or, if you are looking at it from a diagnostic therapy point of view, until the child has reached the level of open set comprehension or the auditory comprehension stage. 

Building Confidence Initially

You want the child to think “I can do this!”  You counsel the parents and let them know that you will be starting at the beginning stages of listening again.  Be sure to give directions while the child is wearing both implants before you start working on the new implant alone activity, especially during the beginning stages.  Use familiar vocabulary, language and stories.  Also include predictable activities.  Be sure to call attention to what the child is hearing, and do not be general about it.  Do not just say “Good Listening.”  Be as specific as possible with the parent and also the child at the level which the child can understand.  Be sure to model positive communication for revision strategy.  Instead of the child saying, “I can’t hear you,” encourage them to say something like, “It sounded like you said…”  I have known children who have appreciated using the external microphone that comes with the implant. 

Tip Top Tips: The Process for Creating Success

Make learning fun through the success in activities.  Be sure to integrate audition speech, language and cognition so that listening becomes a way of life.  It is not just something that the child turns on or turns off at a specific time.  Start at the first step in the hierarchy and continue through that because this follows the natural progression of learning to listen.  We want the child to then listen to learn. 

Then you should use the five E’s at each step, which are:

1.     Expose the child with the auditory presentation.  Always expose before you expect them to come back with anything spontaneous.  Typically is it appropriate to expose the child to the language and vocabulary levels that are one step higher than what the child expresses spontaneously.

2.     Expect a response from the child.   

3.     Let the child Experience, what you were talking about.  If you were describing a bird, reinforce that by letting the child see a toy of a bird.

4.     Then you Expand on to it by talking about the bird outside. 

5.     Then Express.  This is when you return to the activity or you create a similar experience to encourage the child’s spontaneous expression. 

Finally you will re-evaluate your expectations.  Remember to raise your expectations as the child progresses.    

Potential Benefits of Bilateral CI to Consider When Setting Goals and Expectations

What might be some potential benefits of bilateral cochlear implantation to consider when you are setting goals and expectations?  These could be:

• Better hearing in noise
• Better localization
• Hearing at quieter levels
• Improved sound quality
• Improved social interactions
• Faster progress in spoken language and academics
• Stimulating the auditory nerve
• Having a “back up” ear

Amazingly on the questionnaire that I got back from the parents, many parents reported having a “back up” ear frequently as a benefit.  For example, if there was an equipment issue with one ear, the child had the second ear to rely on.  This was pretty important to them. 

Auditory Hierarchy

Today I will be referring to the auditory hierarchy that was published in 1970, 1985, and 1997 by Doreen Pollack.  With each of these stages I will be giving you the goals for each and examples of some activities.  It has been helpful to people in the past to see two specific hierarchies side by side (Figure 1).  Many people are very familiar with the hierarchy established by Norman Erber. 

Figure 1. Erber and Pollack hierarchies.

We start at the top of the triangle and then build the roots as you work down.  You can see in Figure 1 that Erber refers to the base level as “Detection”, while Pollack referred to it as “Awareness”, and so forth. 

Awareness and Attention

     Goals.  In awareness and attention, our goals are for the professionals to assist the child and the family by preparing for optimal CI programming.  That is your basic “I hear it” for presence or absence of sound, loudness or softness, and assuring the child that the implant is working.  One child I worked with was really certain that the batteries were not working since the second implant initially sounded so different from the first.  This is also an important time to obtain baseline evaluation and assessment.  From the child’s perspective, we want the child to indicate presence and absence of sound and also respond to music and singing. 

     Activities.  There are some fun activities to do which are games.  The first one is called “Who Me?”  This is your basic calling game where the child responds to his name (presence and absence).  Then the “What’s That?” game basically is awareness of environmental sounds.  You can call attention to different sounds in the environment.  Do not forget the quiet ones such as the keyboard on the computer or pages turning.  “Shall we Dance?” and “Rocking to Music” are two activities for presence and absence of music.  It is kind of like musical chairs.  In “Shall we Dance?”, when the music comes on, you dance with the child.  In “Rocking to Music,” when the music comes on, you rock, and when it stops, you stop.  Another activity is “Hear Me Sing.”  I have seen a lot of children doing this.  They made this game up themselves when they got their second implant, and this is making up silly songs.  They appreciated attending to their own voice.  It gave them the chance to attend to supersegmentals of speech such as rhythm, durations, pitch, and intensity. 

Auditory Discrimination

     Goals.  These goals are for perceiving that sounds are the same or different.  This includes long and short, continuous and abrupt, loud, quiet, whispered, different pitches and voices, different vowels and consonants.  Another goal is to attach meaning to that context. 

     Activities.   One activity that I have been doing with children is “Who’s Calling?”  This is a step above the “Who Me?” game.  You can use real family members, toy people, or photos of people in the family by putting these photos on popsicle sticks.  You call different familiar names.  In this game, the child is discriminating the difference.  Initially you can set it up to account for a number of syllables and different speech sounds.  Then there is the “Moo, Baa, and Wup, Wup, Wup” game.  These are animals, vehicles, games and books, using a lot of different supersegmentals, different manner of consonants, different production.  It gets more into the speech acoustics as to how you set that up.  Another game is “Who’s That Character?”   This is listening to captioned videos.  I found one family who found this to be a great activity for their child where the child was really practicing attaching voices to the characters.  This was an older child. 

Distance Hearing and Localization

            Goals.  I want to add here that distance hearing and localization actually goes on from the very beginning, precedes and is interwoven among all the levels, but for our purposes, we will discuss it now.  Basically we are expanding the auditory bubble.  Remember that listening is a 360 degrees sense.  We hear even in the dark.  This is where the child is working on locating the source of the sound and then also turning to the source of the sound. 

            Activities.   When you are working on localization, be sure to use both implants at that time because it is really easy to get wrapped up in working with one implant only.  Then when you move on to the localization activity, you may forget to have the child put the first implant on.  In this stage, you can do listening walks, both inside and outside the house.  The “Catch Me if You Can” game is fun.  The way you play this is the person to be caught takes a few steps, increases the distance, and then says “Catch me if you can!”.  The child with the implant has his/her eyes closed and searches for the person by listening.  This is a great game because there is a lot of pitch and intonation in that little phrase.  “Hide and Hear” is a game which is little different than “Catch Me if You Can” because people will hide, stay in one place, and the person listening points to the location.  The child can keep his/her eyes open if the people who are hiding are out of the visual field.  This is fun for a child who may not want to have their eyes closed. 

Auditory Self-Monitoring/Feedback

     Goals.  This is the stage where the connection between listening and speaking really happens.  It is happening from the beginning, but this is when we as the professionals begin to see the outcome of it.  The child is monitoring information through the auditory channel, and modifying speech to match what was heard.  Say what you hear and hear what you say. 

     Activities. One of the favorite activities for this stage is “Wash the Baby.”  A couple of the girls that I have worked with and one little boy loved this activity as well.  Basically what you are doing is creating a language routine according to the child’s level.  In this particular routine, the language that we were inputting was “wash- wash- wash,” “night-night,” and “Shhhh, baby’s sleeping.”  This accounts for differences in number of syllables and manner of consonants.  There are fricatives in there, nasals, and plosives.  There are also voiced/voiceless distinctions.  You can do this language routine many times.  You can do it in the session, in school, and the parents can repeat it at home.  You can add more language as the child gets more comfortable with the self-monitoring. 

This is also the time that we do the babbling unit.  Those of you who are familiar with Doreen Pollack’s work know that this was one of the unique activities that she did in that she took one sound per one week or two and “bathed” the child in the sound with different activities.  For example, if you were using the /g/ sound, we use the tractor as making the g-g-g-g sound.  In this case you could do a lot of activities around tractors and farm activities.  Then you would have some “Go” toys, which are toys that will go after you say to them g-g-g-g-go.  This can also include wind-up toys.  You can wind the toys up, feeding in the “wind-wind-wind” and then holding the toy back until the child tries to say “g-g-g-g-go.” 

Another one that I want to mention which is a classic Doreen Pollack activity was she would put the child on the parent’s back.  The parent would be holding the child and she would take the right arm of the child.  Then she would say “g-g-g-g-go.”  When the child attempted to do this, the parent would then prance around and sing.  They would then stop and the activity would go again.  You can establish activities for each one of the phonemes.  The best way to do this is to collect and organize toys for each sound, and then have corresponding language activities and music activities.  Most families and most children really like doing the babbling units because they are very practical and they are very specific on developing goals.  Then we are back to the silly sounds only on a more elaborate level of just babbling speech sounds with different vowels and so forth. 

Auditory Identification

     Goals.  This is when a child attaches labels to people, things, and actions, and then likewise understands words and the significance of words. 

     Activities.  I will give you some activities for this stage which are probably more appropriate for children who are a bit older, in that it is fun to create a written list with the child if he/she already reads.  If not, you can do it with children who do not read as well.  School-age children tend to love these activities too.  For example, in “Categories with Syllables,” if the category is food, then one example might be “pie” for one syllable, ‘ice cream” for two syllables, and ‘strawberry” for three syllables.  Initially we coach the parent to say one of those and the child selects based on typically one, two, or three syllables.  With younger children, they can use stickers and have younger child put them on pictures.  You will end up with a whole page of food with different syllables.  Eventually and pretty quickly the child can do identification of that and not even be concerned about number of syllables.  Another category could be friends such as “Sam”, “Tanner,” and “Erica”.  Or animals – “dog,” “kitten,” “elephant.”  The other bonus in playing this game is it gives a child a lot of experience and exposure to categories which we all know is so important for language and cognitive development. 

Another game is “Guess the Letter/Name a Word.”  The way we do this game is by telling the child, “I am thinking of the letter T.”  You can have in your mind a list of sounds that differ in manner, differ in place, and that differ in voicing.  These are based on what the child’s present level is, so you are setting the child up for success.  For example, if the child is not yet able with his new implant to differentiate the sounds /p/, /t/ and /k/, then you will not put those sounds all in the same list.  You might instead use a list consisting of /t/, /f/ and /h/.  Back to the example if the letter is T, the child might say “table”.  This reinforces the phonemic awareness.  It take the focus sometimes off of the child working so hard to listen, when the child then begins to feel that they are doing a fun activity or something that they did at school.  It goes back to building their confidence.  These games are done with auditory-only cues, no lip reading.

“Go Fish” is another game.  You can never go wrong with “Go Fish”.  You have cards which have pairs.  You ask the child, “Do you have yellow?” which had been contrasted with “red.”  Or if for example you are working on different verbs, you can have pairs of verbing cards and you may play a verbing Go Fish game, with “Do you have walking?”  versus “Do you have painting?”  You can also take the “Go Fish” game and turn it into a “Concentration” game.  The thing about the “Concentration” game is when you pick up the card or the parent picks up the card, be sure to coach the parent not to show the child the card, but rather provide and auditory phrase such as “I have ‘She is walking.’”  Then the child listens, hears that.  When the child has the correct phrase, then it can be reinforced with the visual card. 

Finally there is the game “What’s my Question?”  This is creating a list of common questions such as “How are you”, “What do you want to do today,” or “Where is your jacket?”  Again the adult asks the question and the child responds with the answer, showing that he knows what the phrase was. 

Auditory Memory and Sequencing

     Goals.  I am linking auditory memory and sequencing together.  Sometimes we talk about these separately, but for our purposes we will talk about them together.  This included following directions, improving auditory memory for words, and remembering words and phrases in the correct order.  I had a parent ask me about this recently.  Typically a child’s ability to remember words in correct sequential order is one item below his memory of items.  For example, if you are doing an activity around clothing for a child with a four-item memory, and the child remembers to “Go get the pants, shirt, shoes, and hat” (therefore, four items), then you would expect the child to remember this in the exact correct sequential order with three items.  They typically develop that way.  The next activity is attending to remembering and recalling stories and books read aloud. This is the best time to be acting out books and doing good children’s literature.  It goes back to finding some great books that are commonly used in schools, all the way out from preschool to high school, and developing materials around them which you can work on with children, whether it is props or word cards for older children.  

     Activities.  One activity for this stage is “Simon Says”.  This is a direction game that all children play.  For example, we might say, “Take two steps forward and turn around.”  Another game is the auditory tracking with props, pictures, print and recorded stories.  This is especially effective for children who read and follow along with the printed text as the parent reads.  You should start out with a familiar book.  This builds their confidence.  The child begins to feel like they are hearing when they are reading and hearing.  Recorded stories are also good.  There are some great recorded activities for the Mercer Mayer books.  This is great for younger children who are not necessarily reading, because they track along with the pictures.  Another fun activity is number, color, noun.  If a child really likes cars, for example, you get out all the cars, put them on the floor, and play with them.  You say, “Can I have three red cars?”  Then you do some parallel play with that.  Then there are tic-tac-toe games.  You can do this both with questions and Math.  You can put a question in each block or if you were doing auxiliary verb questions – with “was”, “is,” “does” - for example, and you ask a question with auditory only input.  An example would be “Does it get cold in July?”  Then the child gets to put an X on the “does”.  Or if you are doing it with Math, which can be fun for older children as they feel they are being challenged, you put numbers in each one of the blocks.  Then you might say, “ 3 + 6”, and the child puts and X on 9. 

Auditory Processing

            Goals.  Our goals are to process units of auditory information and then to make cognitive judgments about that information.  I think of this stage as the time when we are not really giving the answer to the child.  For example, with identification, we are actually saying “Give me the strawberry”.  Here we might say, “I am thinking of a fruit.  It is red.  It has tiny little seeds.”  They have to think about it and then give the answer to you. 

            Activities.  “I Spy” is a great auditory processing activity for descriptions.  You can either do ‘I Spy” with something that is in the room or you could do “I Spy” with something that might be outside or in the home environment.  Another game is “Which One Doesn’t Belong?”  This continues to build the auditory memory as well as the processing.  You would give a verbal list.  An easy one would be something like “happy, big, sad.  Which one does not belong?”  If you have a younger child, you can also do this using toys as props or maybe pictures. 

Question games are fantastic at this stage.  In “What Could You Do With A …”, you would ask, “What can you do with a pail or bucket?”  The child would come up with different ideas.  The important thing to remember is the process through all these activities in that the verbal communication is presented through listening.  “20 Questions’ is another great game.  Some people also think of that game as “Person, Place or Thing’ where you take turns asking questions such as “Is it a man or is it a woman?”  The “Guess Who” game, a game you can buy, is one where the child tries to figure out a hidden person.  They have to ask questions like “Does he have blond hair?  Is she wearing a hat?” 

Auditory Understanding

            Goals.  This stage is when we are thinking it is time that we no longer need to be working with the child, and they are ready to go out on their own.  This is where the child comprehends auditory information in a variety of settings, from different people speaking, at varying rates of speech without acoustic highlighting.  This is without any of the professional highlighting that we do for children.  With the new implant, this is getting ready not be working so much on new implant only, but really letting the child just go out and use both implants, and keep listening and learning.  This is also when the child is also able to communicate with background noise and understanding message from electronic sound sources, and especially understanding phone conversations.  Typically children will try earlier than at this stage to talk on the phone, and they probably do an okay job.  However this is when they are really proficient at it, synthesizing the global meaning of spoken language and relating it to known information.   

            Activities.   These activities are fairly typical activities that all children do such as “Talk Time.”  Talk Time is talking with the TV on, with a CD on, or multi-talkers in the background.  Going to a birthday party hearing what people are talking about and listening to iPod tunes are other activities.  I have a middle-schooler who loves listening to her iPod tunes. 

Partnering with Parents and Professionals

We need to be very specific with parents about goals and activities.  We need to work closely with the audiologist, collaborate with teachers, consider changes in the IEP, and include the child in planning and evaluation of progress if appropriate. 

Questions and Answers

The parents of a three and a half-year-old child are considering a second implant.  At 18 months post-implant, this child is able to auditorially identify 50+ words in closed set.  She does well in quiet therapy, but is missing a lot during preschool time.  How do you foresee the second implant helping in noisier, open-set settings?

I cannot really predict this particular child’s success since I do not know this case.  In general, I can say from what we have been seeing with children with bilateral implants, we could predict that the child will do better in noisier environments.  I would also say to continue to proceed through the hierarchy.  Another thing about this particular case, the earlier the child is implanted bilaterally, the better.  It seems like it might be an appropriate time. 

Do you have a good script to use with parents to explain binaural summation effect? 

I do not have a script, but basically I explain it in a pretty simple way.  I say they are able to hear from both ears so the sounds are adding together.  Then they can hear at a quieter level.  This is a very simple, basic explanation, but maybe a script would be a good thing to have. 

How did you get started in AVT?  I am really interested in what the first steps are?

I got started because I saw a reel-to-reel professionally done movie that the Listen Foundation had made back in the early 1970s called “A Place in Our World.”  I was at Penn State University teaching and I ordered it to show to my class.  I got so interested that I wrote to Doreen Pollack and asked her if I could come and work with her.  I would suggest to you that you contact the Alexander Graham Bell Association for the Deaf (www.listeningandspokenlanguage.org) and you will get information on the Academy of Listening and Spoken Language.  This will give you information that you would need in terms of becoming a certified Auditory Verbal Therapist. 

Donna Sorkin:  In the handout (see "supplemental course materials" link at the beginning of this course) we have listed some resources for you including Start Listening, which is a CD on a set of materials that Cochlear offers for free.  It is actually Nancy Caleffe-Schenck performing a therapy session with a number of children.  It is a wonderful piece.  Listen, Learn, Talk is a video series available from Cochlear. It is about $195 and it is a very nice product for parents to use.  The last item is a text for professionals called Educational Audiology for the Limited-Hearing Infant and Preschooler: An Auditory-Verbal Program (3rd ed.). 

You can find upcoming online sessions at our website, www.cochlear.com/HOPE.  You can also contact us at: https://www.cochlear.com/wps/wcm/connect/us/home

On behalf of everyone from Cochlear, thank you for joining us today.

References

Pollack, D., Goldberg, D. and Caleffe-Schenck, N. (1997). Educational Audiology for the Limited-Hearing Infant and Preschooler. Springfield, Illinois: Charles C. Thomas.

Erber, N. (1982). Auditory Training. Washington DC: Alexander Graham Bell Association, pp. 92-94.