Auditory Comprehension: Focus on Memory for Professionals

Sorkin: Hello everyone, this is Donna Sorkin from Cochlear Americas HOPE Program.  Today we present Auditory Comprehension: Focus on Memory for Professionals with Ashley Garber.  Ashley is a speech language pathologist and certified auditory verbal therapist, and private practitioner specializing in Auditory Verbal Therapy in Michigan.  She has more than 15 years of experience working with children and adults with hearing loss who use cochlear implants and hearing aids.  I am delighted to introduce Ashley today. 

Garber: Thank you for that introduction, and thank you all for joining me to talk about auditory memory.  We will be talking about auditory memory today as it relates to auditory comprehension.  We will get a little science heavy and talk about some research findings for a few minutes, and then we will think about ways to build auditory memory including strategies that we can use and ways to increase contextual support as we work on these structured types of skills. 

Auditory Comprehension

To begin, I would like to talk about auditory comprehension.  Auditory memory is a part of the auditory comprehension aspect of auditory function.  We have spent time building skills from awareness, patterning and discrimination skills, looking at identification skills and now we are in the comprehension area of auditory function.  I would like to reflect a little bit on what auditory comprehension is all about.  Estabrooks and Marlowe (2000) talked about a novel response or generation of new ideas.  Basically, when we show that a child understands the input that we are giving, we would look for some sort of novel response from the child, something that is measurably different than the stimulus that is presented.  In other words, repeating the word that they hear does not necessarily indicate that they understand the word.  That would show only that they can identify the word. 

However, comprehension would be something more than that.  Examples include answering a question, continuing a thought or, in the case of the single word, indicating the object that goes with it, describing an object or paraphrasing.  These are all actions that we would look for from a child that would show that they understand the input that they are getting.  Different scholars and clinicians have categorized auditory comprehension skills in different ways, so I present these few just to compare and contrast.  Stredler-Brown and DeConde Johnson (2004) broke it down into the components of “comprehension”, “auditory memory” and “auditory processing of linguistic information”.  Estabrooks and Marlowe (2000) broke the levels into “auditory memory and sequencing”, “auditory-cognitive skills in a structured set” and then “auditory-cognitive skills in conversation”.  Caleffe-Schenck (2005) describes an organizational framework of “auditory memory”, where we store and recall auditory stimuli, “auditory memory span and sequencing”, where we remember varying lengths of auditory information in exact order, “auditory processing” to make cognitive judgments about auditory information, and “auditory understanding” where we comprehend auditory information in any situation.  Again, these are three different paradigms to look at auditory comprehension.   Auditory comprehension really does encompass so many different areas, but hopefully you notice from each of these three different paradigms that auditory memory makes itself known in each of the three. 

Many clinicians and researchers see that auditory memory is a critical component of overall auditory comprehension.  No matter how we categorize the steps or the aspects of comprehension itself, we do see that it is a critical component.  We can go all the way back to early comprehension skills.  Even comprehending a single word is a culmination of using auditory memory to put together the spoken word with an object or a concept. Being able to retrieve that connection at a later time does require auditory memory.  From the very beginning, a child needs to utilize auditory memory skills to begin to build other comprehension skills.  If we look for a definition of auditory memory, we could say that, in general, this is a process in which we use our hearing to encode, store and then retrieve information.  In order to go through these steps, it is critical that a child have auditory attention.  We will not be able to encourage auditory memory if we have not developed that basic skill for a child in which they will pause what they are doing because auditory information is worth listening to.  Auditory attention is a prerequisite for this auditory memory process. 

I would like to look next at the sub-skills of auditory comprehension that we would be expecting our children to develop.  Consider these for a moment:

• developing memory and concept for a single word
• showing understanding of learn-to-listen sounds
• responding appropriately to common expressions
• following simple directions
• answering common questions
• completing a known linguistic message using auditory closure
• sequencing two, three and four critical elements in a message
• identifying a picture related to a story
• answering common questions about a familiar topic or story 

 If we really think about each of these levels, we cannot identify a single one that does not utilize auditory memory skills to some degree for a child to achieve each subskill under auditory comprehension.  This makes the point that auditory memory is a critical component of this entire auditory comprehension level. 

Research Findings

We will take a minute to understand this area from a more scientific standpoint. I want to examine the correlations between memory skills and the overall language skills of children with hearing loss and cochlear implants.  I have tried to organize this information so that it builds upon itself.  David Pisoni and Anne Geers (1998) published an article where they found a correlation between poor working memory skills and speech perception. The working memory was measured with a digit span task, where the subject listened to a series of numbers and then recalled those numbers.  The performance on those digit span tasks and speech perception, spoken word recognition, language comprehension and reading were all correlated to a child's skill or lack of skill in this area of working memory.  Pisoni and Geers (1998) also proposed that the phonological loop mechanism is directly impacted by auditory exposure and experience, and that it, therefore, may be the key to variable cochlear implant performance. 

When we present spoken language stimuli- words, sentences or digits- that presentation and the interaction between what the child already has stored in their knowledge base is what working memory is.  It is a temporary storage system.  It is the manipulation of information necessary for complex cognitive tasks.  For example, language comprehension requires the information to be stored in the working memory temporarily in order to manipulate that information for the next step.  It is an extension of short-term memory. What is important for us to recognize is that there are four subsystems or processes, phonological loop being one of those four subsystems.  It is the area that is considered to have perhaps the most impact on the research that Pisoni and Geers (1998) published.  Alan Baddeley (2003) has published work outside of the field of hearing loss, but it informs us of the subsequent research that our scientists have applied to hearing loss because he does do so much work in that area.  His work also suggests that the phonological loop impacts typical language development the most of the four processes.  The other three processes have to do with visual input and some other supporting systems.  We as listeners store and rehearse speech-based input.  In other words, when something is presented to us auditorily, we use this phonological loop to consider and rehearse it in our brain. You could think about how you attack a memory task when someone tells you their phone number or gives you a small grocery list. We take the information in and our working memory is activated at that time.  Because this is speech-based input, we rehearse the information over and over again. 

Baddeley (2003) looked at two processes within the phonological loop: a temporary storage system and subvocal rehearsal.  A temporary storage system keeps bursts of information, but memory traces decay unless they are refreshed.  So we hear the information, and we have it held there for a moment, but that information would leave us if we did not rehearse the information with what is called sub-vocal rehearsal.  First we have the temporary storage, but then we do the sub-vocal rehearsal in order to keep it longer in that temporary storage and as part of that phonological loop.  Sub-vocal rehearsal is the process to hold on to that information by practicing it, and we typically do this without speaking.  A little voice might go on in our head, but it is not something that we do out loud.  This routine also happens in order to allow us to process visual information.  Wherever possible, we convert visual information into a phonologically-based system, where even visual sequences of letter or numbers are transposed into a speech-based system in our memory.  We remember the sounds associated with the symbols B, K, W, R, X and Z versus the visual input.   That is part of this working memory. 

Burkholder and Pisoni (2003) published a kind of progress report, which synthesized multiple studies on short-term and working memory processes for children with cochlear implants.  They postulated that deaf children using cochlear implants are less proficient at using short-term working memory due to atypical development of the ability to perform adequate sub-vocal rehearsals, secondary to the perceptual difficulties inherent with severe hearing loss.  They are using the research to look further at what is causing difficulty for children with cochlear implants.  There is a degraded signal and history of delayed language, for example, but they can specifically see that sub-vocal rehearsal is developing atypically for children with cochlear implants.  That very specific aspect of working memory in the phonological loop is something that our children have specific difficulty with. 

In addition, their study (Burkholder & Pisoni, 2003) suggests that the amount and also the nature of the auditory exposure that children receive after cochlear implants will influence performance on all kinds of memory tasks that require that encoding information and verbal rehearsal.  If we think through this, it only makes sense that sub-vocal rehearsal also requires a knowledge base.  Working memory involves holding a particular stimuli and interaction with our knowledge base of vocabulary and language.  So for a child who has a degraded knowledge based due to delayed language acquisition, something that they see visually does not have an immediate phonological representation for them.  That absolutely is going to impact their working memory abilities over time. 

We can put all of these pieces together to see why our children have potential difficulty with working memory.  Research tells us that the phonological loop is a particular challenge for children with cochlear implants, even children who perform very well with their implants.  Our task as professionals who are working with children is to see how we can maximize the skills that they do have.   We need to continue building language and exposing children to quality language from the very beginning in an effort to expand their knowledge base.  Earlier implantation, of course, impacts this. 

Building Auditory Memory Skills

So some of the keys to maximizing success might be to consider the research findings, use effective strategies, emphasize thinking skills while targeting auditory comprehension and then teach across contexts.  We will take each of these areas in turn to consider how we might impact auditory memory, comprehension and success with the implant. 

Taking cues from research

Sub-vocal rehearsal is something that we know we do as typical language learners and listeners.  We use sub-vocal rehearsal to help us remember things.  We can help children with hearing loss also develop those skills.  For example, we might begin by having a child repeat a list of objects, pictures, words or even directions out loud.  The strategy that we use is very familiar:  “Tell me what you heard.”  Of course, this helps to check a child's perception.  If they tell you back what they heard, see whether they have made any perceptual mistakes in hearing something different than what you said.  It also gives them a chance to use that rehearsal strategy, which is a vocal rehearsal strategy in this case, since they will say back what they heard.  As you move forward, you can have the child rehearse that information to himself, then he moves to whispering it or saying the information or quietly, and then not saying it at all but repeating it in his head. 

Use the strategy of turn-taking as an opportunity to model skills for a child.  The child has had a listening turn where you present information and they follow the direction or create the art project.  They you have a turn where they tell you to do something.  Maybe you mouth the words and repeat them as you tick off on your fingers the things that you have heard them list or the directions that they have said to you, so you can show how you use sub-vocal rehearsal to help you remember the steps that are required. 

In doing this, it is helpful to know a hierarchy of skills. The first thing that we want to do when we are building memory skills should be to begin with familiar words.  These are words that are in the child's knowledge base so that when they receive the auditory stimuli, they have a knowledge base to relate it to.  This allows interaction between the stimuli and the stored knowledge base and taps into the working memory.  When we are working specifically on memory tasks, we should use words and language that are familiar.  We can begin with single syllable words and move toward multi-syllable words.  It is more difficult to hold multi-syllable words in the auditory memory for children with hearing loss, but we can work up to that.  A beginning list of words for auditory memory might be words that are phonologically dissimilar.  For example, “cat”, “ball”, “church” and “top” have a variety of consonants and vowels versus the list “cat”, “man”, “hat”, “can”.  In this list, the similar vowel in the middle and many similar consonants will be a much harder list for a child to remember, even though they are all single syllable words.  Phonologically dissimilar words will be an easier task than the more similar phonological grouping. 

Work within categories or contextual groups before unrelated words.  Some of the research findings indicate that perhaps this does not make so much of a difference, but my own clinical experience has been that it is a way for us to teach language at the same time, and children seem to have an easier time with words that are categorized.  Kids may have a greater chance of making a connection with semantically-related words like “peas”, “carrots”, “peppers” and “grapes” than a list of unrelated words.  I find that this is something that I can use as steps up the ladder. 

Keeping working memory working is another aspect to consider; you can help children to extend their working memory a bit by building in delay time. After you have had success working on memory for two or three items, you can build in a slight delay into activities between the time you ask for an object and the time the child gets it.  This is something you can do from a very young age.  For example, instead of having objects right within a child’s reach, place them a little further around the room so that there is just a slight delay between when you say, “Where's the car?” and when the child looks for it or moves toward it in order to get it.  That gives them a little more time to hear the word, process it, keep it in their memory and then act on it.  That gives them a chance to practice that sub-vocal rehearsal.  I know, as an adult, I do this.  If somebody tells me a phone number and I do not have a piece of paper by the phone, I can repeat the number a few times while I look for the pen, and by the time I find the pen I still have the number in my memory because I have rehearsed it over and over.  In therapy, maybe you have a dump truck on one side of the room and all the colored blocks or objects that they are going to put into the dump truck are on the other side of the room.  You would give directions such as, “Go over and give me two red blocks and a yellow block.”  Send them across the room with their dump truck.  That gives them a period of time where they can be practicing, whether it is out loud at first or sub-vocally in their head, so by the time they get to those blocks they still have the information. 

Turn-taking, again, is a very effective strategy you can use in this area of auditory memory practice. One of the primary uses is modeling for the child or parent how it is that you use your auditory and working memory skills to think and remember.  In addition to that sub-vocal rehearsal, Jill Duncan (2007) also looked at some of the other meta-cognitive skills that we can apply to auditory memory.  Rehearsal strategies include repetition, highlighting important facts and physical cues.  Once we get to a level in auditory comprehension where we are using auditory memory to work on listening to a story and then paraphrasing it or repeating it, one of the things that we need to do as a listener is remember what is important.  Not everything is important, but there are bits of information that should take precedence, and that skill comes as part of our rehearsal strategies.  We can use elaboration strategies where we create mental pictures and paraphrase ideas, and also organizational strategies where we put the important bits together, group, classify and identify the main ideas.   Thinking about past ideas or passages and discussing them helps build our memory. 

One very effective strategy is acoustic highlighting.  This is a tool we can use to our advantage as we work with children to build in more language.  We can use our voice to emphasize the key words and features of words.  A specific strategy for a memory task is chunking information.  We can use our voice to pause before and after the important information.  This puts it into manageable bits.  Think about telephone numbers again.  We remember those by chunking the information:  555 (pause) 867 (pause) 5309.  We may also memorize numbers with a melody or rhythm.  This helps us remember what could be a more difficult memory task like digit span, for example.

Here is a language-based example:  “Put the baby on the bed and the doggy on the car.”   Say we chunk the information as follows:  “Put the baby…on the bed…and the doggy…on the car.”  You have chunked the information, and then you add a little rhythm.   Children can grab on to those chunks and use them for their own sub-vocal rehearsal. 

Another strategy that we talked about throughout discussion of auditory skills, whether we are looking at patterning or identification skills or comprehension, is wait time.  Pausing before auditory input is given allows the child to attend more closely.  If you let the child know there is something coming and give a pause before you start with the important information, they are going to be more ready to take it in.  Then, after the fact, they need some time to process what they have heard.  Give a moment for them to think about it before repeating something.  If we repeat or rephrase too soon or too often, we will interrupt the child's internal rehearsal strategies.  If they are working on sub-vocal rehearsal and we jump in with a repetition, maybe we have stopped them right in the middle of the process.  Make sure that you give them enough time to process the information and to move into that stage of sub-vocal rehearsal.  Of course, it might be necessary to repeat sometimes, but using that wait time after you present something will give you an opportunity to find out whether they need it or not.  This may be a hard skill for some to use consistently, especially if you are eager to talk and help the children with information.  Be comfortable with the silence.

The third way to maximize progress and auditory memory is to think and listen.  In this context, thinking and listening is all about helping the child make auditory connections.   At an early age, there are connections between what a child is hearing and what he is seeing and touching.  We stimulate language and cognition concurrently.  Of course, as language grows, so does the connection between what a child is hearing and its relationship to the greater world around him.  We use language and listening as the bridge to higher-level thinking skills. 

It is important to be aware that we will cycle through language.  As with other comprehension skills, language is inextricably linked.  Therefore, we must cycle through higher language levels with the same auditory goals as they are achieved.  If we look at an auditory skill curriculum, we have a certain number of subskills: memory for one object, memory for two objects, memory for two directions, sequencing, et cetera.  We could look at these on paper and consider these to be discreet skills, but we cannot ignore that the auditory component is directly tied to the language, and that these are linked in such a way that a child still needs to work at using those auditory skills as they move forward in language development.  Following two-step directions could use very simple language and the child could achieve it, but if we stop there, then we have not facilitated their movement toward following two-step directions with much more complex language.   As we cycle through higher language levels, we use higher levels of vocabulary and use more complex grammar. 

Here are some examples.  The auditory goal is recalling two critical elements.  We might start with something like, “Get the ball and the bear,” but if the child is successful and we stop there, we have not challenged his memory with words with a greater number of syllables; something that we noted to be a more challenging task.  More complex vocabulary might be, “Get the ball and the stapler” or “Get a stethoscope and some tongs.”  We need to approach auditory comprehension tasks from an auditory memory perspective as we increase the language and vocabulary demands.  This is all hierarchical in nature. 

Next is following directions containing four critical elements.  We have a similar concept here as we cycle through language.  For example, “Throw the ball, wave to the girl.” Those are your directions with four elements.  “Toss the ball to the nearest female.”  You can see the differences between these two sentences and how the language requirements are building.  “After the hike, pass it to the receiver.” This one, of course, has much more complex language structure where the sequence of action is changed by the language.  There are still four critical elements, but the complexity of language has increased.  So we cannot stop with the first level and say, “Yes, this child can follow a direction with four critical elements.”  We need to keep working from the auditory perspective as we move through language goals.  Hopefully that will encourage any of you working with children who seemed to have finished their auditory skill curriculum but still have language goals on the individualized education plan (IEP).  Recognize that they still should have long-term auditory goals written into the IEPs because they are inextricably linked to the language that you are building. 

Our last topic in the area of maximizing skills is moving toward natural context.  As we are working on these memory skills, I think we are tempted to be quite didactic and very structured where we use closed sets of objects and follow directions, but I try to remember to make auditory memory activities fun and relevant to the greater language targets that I am building.  I try to put things into context in order to build that stored knowledge base that is a part of that working memory system.  So as you are preparing your activities, think about natural opportunities in which you can require children to remember multiple items.  When does it come up in your day that you are required as a listener to remember multiple objects?  When is it typical for you to have to put things in order?  When is it natural and necessary to repeat events?  Approach your therapy from a natural, contextualized kind of a place. 

For example, a hamburger stand could be a good pretend play setting for directions.  “I will have a burger with cheese, ketchup and pickles.”  That is memory for three items.  That is a very natural setting.  The person behind the counter has to remember what the customer asked for.  “Make my burger with tomato on top and cheese on the bottom.”  At an ice cream stand, “I will have three scoops: chocolate, vanilla and mint with the vanilla not touching the mint.”  Some customers are very picky, so that is a time when you need to remember the order in which things are given to so that you can complete that task to the customer’s satisfaction.  At a jewelry shop, “Would you make my bracelet with three red beads, then a blue bead and then two more red beads?”  This is another time when order might really make a difference.  A reporter might say, “Today at the park a man threw a Frisbee into a tree, and a squirrel ate a girl's sandwich.”  That is an example when it is important to remember all the events that happened so that you can repeat a paragraph or a conversation.  These are just some brief examples of how we might think about contextualizing auditory memory within things that we do. 

Here are some other favorite memory games, which I can recall playing even back in my Girl Scout days.  The “Telephone Game” is great for a classroom or a group setting.  One person has something to say and they tell or whisper it to the person next to them, and then that person has to remember exactly what was said and whisper it to the person sitting next to them, and so forth until it reaches the last person in line.   Hopefully the last person repeats back exactly what the first person said, but it can be comical how the message is changed from person to person.  That is a fun way to work on auditory memory and sub-vocal rehearsal.  You can even work in where each person has to take a minute before sharing with the next person.   “Going to Grandma's House” is a game where you have to virtually pack a suitcase.  “I need to pack my suitcase with an apple, ball, cupcake…” Each player adds to the list and the next player has to recite the entire list and then add one more item.  “Simon” is another game.  Maybe you are familiar with it:  It is an electronic board with colored panels.  First the yellow panel lights up and then the red and then the blue and then you take a turn pressing the colored sequence.  Now, this is a visual game, but if we think about how we do something like this, we use that phonological flip where we process visual information in an acoustic way.  So when the colors light up, I would say to myself, “Yellow, blue, red.  Yellow, blue, red,” and press the sequence of colors as I say it.  The longer you play the game correctly, the sequences become lengthier, making it more difficult.  So we can look at some of these visual games and recognize that these are just as helpful at working on auditory memory because we assign a phonological pattern and can use sub-vocal rehearsal.   That should be information that is typical for young kids and part of their knowledge base so we can draw on that for practice.  

“Memory” or “Concentration” is another game.  When we play this game in the traditional way, we turn over a card that has, for example, a dog on it and then we turn over another card looking for the match.  Again, even though it is a visual game, we flip it into a phonological signal and we say, “There is a dog here and a plum there.” Then when we are trying to remember where they are, we remember it with that word in our brain.  We can also modify and make it auditory-only.  For example, on my turn, instead of turning the picture over, I just flip it up where I can see it and say, “I got a dog,” and put it back down where the other player cannot see it.  Then we have to use our auditory memory and hold that information there while we remember what the other person saw.  We can use some sub-vocal rehearsal right away to remember the cards, but it also carries throughout the game. 

The last point I want to make quickly is about adding music.  Tierney, Bergeson-Dana and Pisoni (2008) found that music can increase verbal rehearsal and the ability to maintain and increase attention to auditory memory tasks.  There is a definite correlation between music and language.  I recently attended a session at an ASHA conference where they talked about the correlation between musical training and improved literacy skills. We can never go wrong with adding music and rhythm into our therapy sessions or talking about the importance of music with parents. 

Summary

By taking each level of auditory function in turn, we can examine its significance and consider our approaches of teaching.  As one aspect of auditory comprehension, auditory memory deserves special consideration for its link to the variability in cochlear implant performance.  Added attention to strategies that both recognize and move to combat the difficulties that children with cochlear implants have with working memory skills may serve to improve outcomes.  We can impact these areas the therapy strategies. I appreciate your attention today and hope that you have found something to take back to your place of work or your home.  Thank you very much.

References

Baddeley, A. (2003). Working memory and language: An overview. Journal of Communication Disorders, 36(3), 189-208.

Burkholder, R. & Pisoni, D. (2004). Working memory capacity, verbal rehearsal speed and scanning in deaf children with cochlear implants.Research on Spoken Language Processing, Progress Report No. 26 (2003-2004). Retrieved from: https://www.indiana.edu/~srlweb/pr/26/47-Burkholder.pdf

Caleffe-Schenck, N. (2005). Auditory-verbal therapy: Developing spoken language through listening with children who are deaf. In CNI Review, Colorado Neurological Institute. Retrieved from: https://www.thecni.org/documentfiles/16-spring05-p12-caleffe-schenck.pdf

Duncan, J. (2007). Goal setting for advanced students. Presentation at Royal Institute for Deaf and Blind Children.  

Estabrooks, W. & Marlowe, J. (2000). The Baby is Listening: An educational tool for professionals who work with children who are deaf or hard of hearing. Washington, DC: Alexander Graham Bell Association.

Pisoni, D. & Geers, A. (1998). Working memory in deaf children with cochlear implants: Correlations between digit span and measures of spoken language processing.  The Annals of Otolaryngology, Rhinology & Laryngology. Supplement, 185, 92-93.

Simser, J.I. (1993). Auditory-verbal intervention: Infants and toddlers. The Volta Review, 95, 217-229.

Stredler-Brown, A. & DeConde Johnson, C. (2004). Functional auditory performance indicators: An integrated approach to auditory development. Retrieved from https://www.cde.state.co.us/

Tierney, A.T., Bergeson-Dana, T., & Pisoni, D.B. (2008). Effects of early musical experience on auditory sequence memory. Empirical Musicology Review, 3, 178-186.

Walker, B. (1995). The auditory learning guide. Retrieved from https://www.firstyears.org/c4/alg/alg.pdf