Auditory Expectation

What does it mean to have an auditory expectation for children with hearing loss in therapy and in life? First of all, it means that I, the adult, have done my part in giving you the tools (auditory access and a good listening environment) to be successful. Once that has been established, an auditory expectation means: I trust your hearing.  I assume that you will listen.  It’s not a “set to listen” condition, where constant prompting is needed.

The famous “Listen!” cue in AVT (the adult says, “Listen!” while pointing to their ear) can be helpful to cue a new listener to perk up and pay attention to auditory information. As an example, let’s consider a fifteen-month-old baby who just received bilateral cochlear implants three months ago. The parent and Auditory Verbal Therapist are working together to help establish the child’s detection response. The child is sitting facing the mother, who points to her ear and says, “Listen!” Outside the room, the therapist knocks on the door. When the child demonstrates awareness of the sound (detection), the child and parent walk to the door to open it and let the therapist in. This is a “set to listen” condition.

But too much prompting to listen becomes a bad thing. Think about it: typically-hearing people with strong language and listening abilities aren’t always prompted to “Listen!” before receiving auditory information. If I said, “Listen!” every time I wanted to tell my colleagues something, they’d look at me like I was out of my mind. It’s not pragmatically appropriate. (“Listen! How are you today?” “Listen! Those reports are due at 5PM.” “Listen! What did you do this weekend?” … sounds weird, right?) Most people don’t consciously turn their listening ability on and off. Of course, we all tune out (consciously or unconsciously) from time to time, but you’re generally aware of what is going on in our listening environment. You alert to environmental sounds (phone ringing), answer questions people ask you, or turn if you hear your name.

So how do we get from a “set to listen” condition to auditory awareness? It’s not so black and white. Instead, I suggest that there are a range of strategies we can use to build auditory awareness. For a child who has less auditory awareness and requires more visual support, you might start by saying “Listen!” and giving the visual “Listen!” cue of pointing to your ear. Then, use just the verbal cue or the visual cue for “Listen!”. Next, eliminate “Listen!” cues altogether and just give a meaningful expectant look. For a child who has some established auditory awareness and requires less support, you might call their name, use an auditory hook (like saying, “Hey!” or “Guess what?” or starting your message with some emphasis or acoustic highlighting). Once the child really gets it and does have that auditory awareness orientation, just say your message!

It’s Not a Secret!

I had a horrible experience teaching my graduate-level aural rehabilitation class earlier this semester. One of my brilliant students, herself a young woman with hearing loss, came to me during office hours to discuss audiogram interpretation. We talked through the concepts, worked through an example together, and things clicked! Happy story, right? But then she said something that absolutely broke my heart…

“Nobody ever explained this to me before!”

This student had been identified with hearing loss as a toddler and gone through the last twenty years of her life completely in the dark about what was going on in her very own ears and brain. She was accomplished enough to make it to a master’s degree program and yet no professional she’d ever encountered over the previous two decades thought to explain her hearing loss to her? That is borderline criminal! (just kidding… kind of!)

Now, I don’t know those professionals, and I don’t want to completely throw them under the busy — maybe they did explain and she forgot, maybe they had an impossibly large caseload and were too busy, maybe they barely understood audiogram interpretation themselves (another problem for another article on another day!). But maybe they also thought it was “too complicated” for her or her parents to understand (English is not their first language), maybe they assumed she didn’t need to know all of the technicalities — just put these hearing aids on and you’ll be fine, maybe… Who knows?

All I know is my message to all of you reading today: Don’t be that professional. If a person has hearing loss, they deserve to know about their hearing loss. This can start with very young children knowing the appropriate names for the devices they use to slightly older children learning how to describe their degree and type of hearing loss, how to interpret their audiogram, and so on.

Deaf is not a bad word, and hearing loss should not be a secret. As family-centered professionals, we have an obligation not only to provide excellent services, but to explain the what, why, and how behind our recommendations.

Understanding one’s own hearing loss, hearing technology, and hearing testing is an essential part of self-advocacy.

Get Comfortable Being Bad at This

I often think of my first-ever patient. We’ll call her Callista. I was a rising senior undergraduate taking on my first practicum assignment in my university’s training clinic. Sure, I’d had volunteer placements and part-time jobs working at auditory-oral preschools for children with hearing loss since middle school, but this was the first time I was the one in charge of planning and executing therapy. I knew I was going to rock it.

Spoiler alert, dear reader — I did not rock it. I don’t remember much about that summer, but I do recall Callista bursting into tears and me frantically promising her that we could paint our fingernails during the next session if she would just. calm. down. It was not my finest clinical moment. May all the powers that be bless Callista, because if she’s a competent communicator today, it sure as heck isn’t because of anything I did that summer.

I wasn’t a great therapist that summer, and I wasn’t a great therapist by the next summer, or the one after that, either. The one thing I had on my side was my willingness to try. Not to “fake it ’til you make it,” but, in the words of social psychologist Amy Cuddy, the drive to fake it ’til you become it. Too many pre-professional students (and professionals in the field!) are scared to try something new because of the reality that most of the time when you try something new, you’re really, really bad at it for a while. I was incredibly lucky that I had so many places willing to let me volunteer, give me a part time job, or get me into clinical placements early so I had time to practice being bad at new skills before going out into the real world of solo clinical practice.

Consider the 10,000 Hour Rule popularized by Malcom Gladwell’s book Outliers, which proposes that you need to do something for at least 10,000 hours before you become an expert who is able to perform a complex task naturally with skill and ease. The reality is more complicated — learning and expertise are undeniably multifactorial — but the assertion that you need lots and lots of practice to get good at something rings true. You don’t get those 10,000 hours by watching. You get them by doing. Doing a lot. Doing it badly, learning, and doing it again. And again. And again.

This week, I encourage you to be as blissfully unaware as I was (and still am!) about the limitations of my own abilities. Try something new. Paint those nails messily. Totally flub an AV technique. Put yourself out there!

Being bad is only BAD if you don’t get better.

Just Floss One Tooth

Sometimes, tasks can be overwhelming and we let the perfect be the enemy of the good. I was having a conversation with a mentee the other day when she shared a wonderful insight with me: Just floss one tooth.

We were talking about performing daily listening checks to ensure that hearing equipment is functioning well. Those daily Ling Six Sound Checks (or LMH-10 Checks) are simple to perform and so, so important (read the linked articles to find out why). But simple and important or not, if you’re a busy parent trying to wrangle an antsy toddler in the mornings, taking time out to do these checks can seem nearly impossible. As an auditory verbal therapist, I am very invested in making sure children have optimal auditory access to achieve the goal of developing language through listening. As a human who struggles to implement daily practices (*ahem* flossing) that I know will help me but just seem like one more thing on the to-do list… I get it.

Enter the “just floss one tooth” philosophy. All six (or ten) sounds feel like too much? Ear-specific checks just a bridge too far? Just do one. One sound, one device, one day a week… whatever it takes to make this feel manageable. The perfectionist and auditory brain fanatic in me cringes, but honestly, this strategy is more likely to lead to long-term adoption of better habits, not less. Making a big commitment feels intimidating. Taking a tiny step feels doable.

You can apply this to anything that is a struggle for you or the families you serve. Commit to using one new AV technique in your practice just once, and see how it goes. Read just one page of that article that’s been sitting in a tab on your browser for weeks. Help your child keep their devices on for one hour today. Just like flossing just one tooth, who knows? It might feel so good you’re motivated to do more tomorrow!

Putting Out Fires (Or, “Why Some Families Don’t Seem to Care About Things that Professionals Think Are Important…”)

Sometimes I am working with a family, or speaking to a mentee who is working with a family, of a child who is exhibiting significant delays. Perhaps the child’s technology is poorly programmed, infrequently used, or both. Maybe the child’s educational and therapeutic situation leaves a lot to be desired. Whatever the cause(s), this child is struggling. As someone who has …ahem… been known to be a bit dramatic from time to time, I sometimes see these situations and think, “Oh my gosh, if this was my kid, I would be treating this like an emergency. I’d be pulling the fire alarm!”

And some families react this way, too, and put out an all-hands-on-deck response to their child’s delays to help them optimize their potential. But others don’t. And some don’t seem too terribly bothered by the delays, either. That used to both perplex and perturb me. And then my own fire alarm comment got me thinking… You don’t pull the fire alarm on burnt popcorn if the house is burning down. In other words, some families aren’t or don’t seem bothered by their children’s delays because they have much, much bigger fires to fight in their lives.

You don’t pull the fire alarm on burnt popcorn if the house is burning down.

It’s hard to get up in arms about your child’s hearing aid wear time if you’re worried about making sure your child has something warm to wear. It’s hard to stress about whether or not you’re implementing home carryover if you don’t know where you’re going to call home each night. It’s hard to worry about your child’s knowledge of food vocabulary if you just want to make sure your babies have food.

Now of course, this is not always the case. Some families of children who are exhibiting delays may be meeting them in a way that seems even-keeled or unbothered to us because that’s just their temperament, or perhaps they have different expectations for their child. That’s important for professionals to know about, honor, and reflect in our treatment. But I would argue that the vast majority of parents who seem not to grasp the gravity of their children’s delays a) actually do grasp the delay (they’re not stupid) and b) just don’t have the emotional wherewithal to go attack the problem (or to attack it in ways professionals would deem appropriate/acceptable).

So what can we do in these situations? We should be empathetic, yes, but our job is to help parents help their children with hearing loss learn to communicate. We can’t just throw up our hands and say, “Well, you’ve got a lot stacked against you, so let’s just let language slide.” The long-term neurological, educational, and social consequences of giving up are just too great. It’s also not our job as communication disorders professionals to be all things to all people. We are not psychologists, social workers, food bank operators, or rehabilitation centers, and we shouldn’t pretend to be. But we absolutely should know of these types of professionals and resources in our community and share that information with families who may be fighting those particular kinds of “fires.” To take. the fire analogy further, we need to fight it on multiple fronts: connecting the family to resources that might help extinguish some of the other fires in their lives, crafting our intervention so that it fits seamlessly into their daily routines and is not adding another fire to their list, and helping children and families build resilience so that they can be truly fireproof.

Give Me Five!

You may already know how I feel about flashcards (spoiler alert: I hate them), but there is something to be said for repeated practice as a way to cement new skills. So how do we help children with hearing loss improve their articulation in a way that allows them enough opportunities to practice without resorting to drill-and-kill? Give me five!

Consider this scenario: A little girl with bilateral hearing aids is baking with her mother. One of the ingredients is cinnamon, which the little girl pronounces “cimmamon” (darn those trickily similar nasals /m/ and /n/ all mixed up in that multisyllabic word!).

STEP ONE: Catch and correct!

Once the adult communication partner (here, the mother) notices the child’s misarticulation, it’s time for a catch-and-correct. The adult can use strategies like the auditory feedback loop (“I heard you say cimmamon, but it’s cinnamon”) and acoustic highlighting (“Listen. The word is ciNNamon“) to help the child improve her production.

But that’s not enough! Modeling the word with acoustic highlighting helps the child lay down new “brain tracks” to build a correct internal model of how this word should sound, but it doesn’t give her an opportunity to practice the motor patterns necessary to produce the word correctly. So it’s time for step two…

STEP TWO: Give me five!

Now it’s time to move from perception to production. I like to build the child’s metacognitive skills and emphasize, in an age-appropriate way, that it’s all about the brain, by saying, “Let’s make sure your brain remembers that new word and say it a quick five times.” Then I hold up my fingers as the child practices saying the word correctly, 1… 2… 3… 4… 5!

The level of support necessary will vary by child and by word. Sometimes the child needs a model each time to practice the word. Sometimes we can provide a model for the first few attempts and then fade it out so the child produces the word independently. Sometimes the child is producing it correctly and independently from trial #1. If the child can get the word (with or without support), knock out a quick five to cement that motor pattern and auditory feedback loop and move on!

Two caveats to keep in mind:

No wrong practice! If the child is struggling to produce the word even with modeling and support, don’t have her practice it wrong five times. Dig deeper to find out where the breakdown is occurring and work on those prerequisite skills.

You know your child best. Sometimes they’re in the right mood for a catch-and-correct + give me five, sometimes they’re not. Don’t push it and make the communicative interaction unpleasant. Keep it light, fun, and focused on connection and success.

Moving forward, we’re going to take the information obtained from the child’s error (mistakes are such awesome learning opportunities!) and weave it into future activities for more practice, but the point of the catch-and-correct + give me five strategy is to help the child improve production, give a bit of practice to solidify the new skill, and move on.

LSLS Mentor Quality Checklist

Are you considering Listening and Spoken Language Specialist (LSLS) certification? One of the first steps is to reach out to a mentor — someone currently certified who will work with you over the 3-5 year candidacy period. A good mentoring relationship can be transformative for your career. A bad mentoring relationship? Yikes…

If you’re looking for some guidance on the qualities you should look for in a prospective mentor, here you go! Presenting… the LSLS Mentor Quality Checklist!