Graduation: When Do We Finish with Therapy?

Long ago, many children with hearing loss received “speech therapy” well into their teen years and beyond.  Thanks to newborn hearing screening, early intervention, and great hearing technology, the world is changing!  Now, we find ourselves asking, “When is a child with hearing loss ready to graduate from auditory-verbal therapy?”  More correctly, because therapy is a family affair, we should really ask, “When is a family ready to graduate from AVT?”

For children in my practice, my goal is that they should achieve age-appropriate (or above!) scores on standardized tests when compared to their hearing peers.  Given normal cognitive abilities and no other complicating conditions, this is very achievable!  Though the average range for standard scores on standardized assessments is from 85-115, with 100 being the absolute mean, I prefer for “my” kids to be in the 100-115 half of that range.  Though 85 is technically “within normal limits,” that score gives the child zero wiggle room to account for a noisy classroom, a bad day, a teacher with an accent that’s hard to understand, etc.  It’s too close to the edge and I’m not willing to risk it.  If the child, minus the hearing loss, has all factors in place to be capable of receiving a score 100+, then let’s not let the hearing loss limit her!  That should be our expectation.


But standardized assessments alone don’t tell the whole picture.  I also want to know that the child is able to use these speech, language, and listening skills in real life.  If we sit and have a conversation and I take a language sample, am I hearing age-appropriate grammatical structures that I can mark off on a criterion-referenced assessment?  Are the parents reporting generalization of goals at home, or does the child do well thing in therapy but forget the new skills once she walks out the door?  Is the child able to have conversational interactions with family, peers, and strangers and be understood?


Today, we are discharging families from therapy long before the child is finished learning language.  A four-year-old with hearing loss who is age-appropriate and ready to graduate is not finished with her lifetime language learning.  No four-year-old is!  That’s why family participation in AVT is so critical.  If I have done my job and given the parents the skills they need and techniques they can use to make speech, language, and listening a part of everyday life, they should be able to continue to grow their child’s language long after they leave my caseload.  The goal is that the child should continue to learn along a developmental trajectory just like her hearing peers.  Parents should graduate with a full toolbox of techniques and the ability to advocate for their child.  If the parents have learned to make AVT a lifestyle and become their child’s first and best teachers, they can take the reins!


Before graduation, I also want to make sure that the child has shown signs of three other important lifelong skills:

  1. The ability to self-monitor and self-correct.  Does the child have a well-functioning auditory feedback loop?  If so, she can continue to improve her own speech and language.

  2. The ability to self-advocate.  Can the child request repetitions, put her device back on, explain why she needs her CIs?

  3. The ability to learn incidentally.  Can the child pick up new words, language structures, slang, etc. from the environment?  The parents and I will never be able to explicitly teach the child all she needs to know, so we need to optimize technology and listening skills to make sure she can continue to learn on her own.

Now, of course, these three skills will look like different things for graduates of different ages.  I would expect a much less sophisticated answer to, “Why do you wear hearing aids?” from a five-year-old graduate than a ten-year-old one, but the general principles apply to children of all ages.


Timing is important, too.  I find that the best “graduations” are actually gradual transitions, not a drastic cut-off of “one day you’re in therapy, the next day you’re out the door!”  Generally, I like to phase the child down to every other week, then monthly sessions (each for about a “semester” of time), and then twice-yearly check-ins for the remainder of the child’s school years to update testing and ensure that appropriate progress is being made.  This “step-down” plan helps the child and family feel supported as they move to independence, and also allows us to watch and wait to make sure the child continues to progress as therapy time decreases.  I want to see the child obtain average/above average scores not just once, but also to maintain those scores over time.  I want to see their skills grow just as the language demands grow based on their age.  If the child doesn’t continue to move forward, it may not be time to decrease the frequency of therapy just yet.


It can be scary for families to take the leap from the warm safety net of a weekly therapy appointment to building language out in the big, wide world, but we do children and families a disservice when we over-serve them, either with too many appointments a week or by keeping them in therapy for too long.  My job is to make myself unnecessary by building the family’s skills.  Programs sometimes want to hang on to their high performers, feeling that a child who is above age-appropriate will be “a good model for the other children” or make their program look good.  To me, that is selfish.  As a parent, your responsibility is to your child, and she goes to therapy to get therapy, not to be put to work as a model for the other children or as an advertisement to fuel egos or solicit donations.  The real world is out there.  If you’re ready, a good therapist will give you wings to fly and a push to get you going!


But what about special cases?  For a child who has hearing loss and additional disabilities, achieving age-appropriate listening, speech, and language skills may not be a realistic goal (note that I said may — some of these children absolutely CAN!).  In these cases, I like to think, “What would I expect from a child with this disability without hearing loss?”  If a child with Down syndrome and hearing loss is scoring up to his cognitive potential when compared to other children with DS, that is great!  A child with many conditions is ready to graduate from therapy when the hearing loss is no longer the factor that is holding him back.  At that point, it may be time to transition to a specialist who can help the child work on his other issues.  For example, once a child with hearing loss and autism has learned to listen with his CI, he may be better served by an SLP who specializes in the pragmatic (social communication) deficits common in people with autism spectrum disorders.  We have to look at the whole child — sometimes, hearing loss is the least of their concerns.


Sometimes, a child has ceased to make progress in therapy and we can’t point to any other cause, like an additional disability or equipment failure or the need for more aggressive mapping.  Therapy becomes frustrating for all involved.  The first step is always to look for red flags and try to puzzle out what exactly is causing this developmental plateau.  Often, a thorough investigation of these factors will lead to a solution and you’ll be back on your way.  But for some children, particularly those who were late identified and have been in therapy for a while and probably will continue to be in therapy for a lot longer, there can be times when all of us (parents, child, and therapist) just need a break.  Is it ideal to stop therapy for a few weeks, a month, a summer?  No.  But if the child and family return refreshed and ready to move forward, you may recoup your losses and make even more progress than you would have had you continued slogging along.


Parents also need to be aware of signs that it might be time for their child to head back to therapy, even years after graduation.  It is not uncommon for children on my caseload to be done needing my help by the time they start preschool.  Will they still be doing well in third grade?  For many, the answer is yes, but for some, maybe a tune-up is in order.  This is where checking in regularly with your AVT is important.  We (the child’s team — parents, therapist, school staff, etc.) can stay on top of the child’s progress and intervene if needed before the child ever has a chance to fall too far behind.  If you notice changes in your child’s listening, language, and speech, if the child is struggling in school or not relating well to peers, if you feel that your child isn’t growing her skills like other children her age, come back to therapy!


The last important thing families need to know is that graduation is not goodbye forever.  I continue with twice-yearly checkups as long as the child is in school, and one of the best parts of my job is staying in touch with former families and watching their children grow up and achieve great things.  AVT is a partnership that lasts a lifetime.


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