Meet the Authors: Susan G. Allen and Shefali Shah
Susan G. Allen, M.E.D., CED,
M.Ed., CCC-SLP, LSLS Cert. AVEd
Shefali Shah, M.E.D., CED,
LSLS Cert. AVT
Tell us a bit about yourself and your professional background.
Shefali Shah: I have always wanted to work with babies and young children because that’s where it all begins! I feel privileged to have been mentored by Warren Estabrooks, who continues to be my professional guide. As India’s only practicing LSLS Cert. AVT, I know that the work ahead has as much to do with guiding families in therapy as it has in training professionals. I have worked with over 90 babies and young children and their parents from across India, built a team of professionals and was director of the I Hear Foundation’s early intervention centre, Naad, which I recently left to establish a private practice in Mumbai, India. I have also developed and instituted India’s first training program in auditory-verbal therapy.
It is remarkable that Susan and I were partnered to work on Question 49 in 101 FAQs About Auditory-Verbal Practice (Estabrooks, W. Ed. 2012). We both graduated from the Smith College - Clarke School for the Deaf Teacher Training program. This collaboration, a first for me, has been amazingly satisfying. It is heartening to work with someone half way across the world on a topic that both of us are passionately interested in. I thank Warren Estabrooks and AG Bell for this wonderful opportunity.
Susan G. Allen: Upon graduation from the Clarke and Smith program, the same program as my colleague Shefali, the president of Clarke said to me at the time: “The best thing you have learned is what children who are deaf can do and the worst thing you learned is…what children who are deaf can do. This advice has always driven me to “raise the bar” for deaf children and their families for the 48 years in my professional career. I am most proud of being the founder and former director of the Clarke Schools for Hearing and Speech in Jacksonville, Fla. for 16 years.
I am the author of the Auditory Perception Test for the Hearing Impaired-Revised (2008), and co-author of an earlier version, APT/H, (1994). I am also a co-author/editor with Dr. Todd Houston for the soon to be published From Assessment to Intervention, A Guidebook for the Auditory Perception Test for the Hearing Impaired-Revised (Plural Publishing, Inc.) I have 48 years of experience teaching children who are deaf to listen and to develop intelligible speech and oral language. I have presented over 100 papers, courses, and workshops and have been invited as a keynote speaker and lecturer at several conventions and universities nationally. Additionally, I have gladly mentored many professionals and have served on several committees and boards for children with special needs.
In FAQ #49, you say that the presence of hearing loss tends to freeze parents’ spontaneity with their child. Can you share some techniques and approaches that have worked particularly well in your practice that can be helpful to your colleagues?
Susan G. Allen: Finding out that your child is deaf or hard of hearing is, first and foremost, very emotional for the parents. From my experience, their first thought is, “…all my dreams for my child have been shattered.” Most parents become overwhelmed and terrified when they first hear the diagnosis from their audiologist. The deafness overshadows the typical responses they would have—had their child had typical hearing— and they tend to “freeze” with their child. It diminishes their spontaneity because they are thinking of the hearing loss and not the child as a whole. At birth, they may not even talk to their child because they think the child “can’t hear.” There are so many misinterpretations in these early months.
This is where it is extremely important for the professional to counsel the parent about hearing loss and options, give the information to assuage their fears, guide them, and support them. This is also why appropriate and quality early intervention and auditory verbal practice are so important to the family that says, “I just want my child to say, ‘I love you mommy, I love you daddy,’ and order a hamburger at McDonald’s.” Listening to the parent, determining their goals for their child, going through the process necessary to achieve their goals, and actually showing those children who are going through that process helps to inspire them and assuage their fears. I remember parent after parent walking through our early intervention program and our school and watching deaf children listen, talk and sing helped them realize they could still have those “dreams” come true.
Technology provides access to sound and it also changes so quickly these days. How do you keep up with advances in technology? What do you recommend to parents who want the best for their child?
Shefali Shah: This is truly an exciting time in India, as we are now connected to the worldwide web of technology! It is no longer a question of access; it is merely a willingness on the part of us professionals to stay connected to the global changes in technology. My clinic and I have excellent relationships with all the leading manufacturers of hearing aids and cochlear implants. We are constantly working together on staying abreast of the changes and upgrades in their technologies and applying them to our practice in auditory-verbal therapy with young children. Staff is trained on an ongoing basis by the manufacturers both overseas and in India and we participate in their clinical research trials and attend collaborative workshops and meetings. As a LSLS Cert. AVT, I am a member of the worldwide circle of my fellow professionals: an important, enriched source for second opinions on issues in clinical practice, audiology, referrals and additional services. Families at my clinic are the first and direct beneficiaries of this ongoing collaboration, as we organize periodic workshops to update them on changing trends. Today, India’s parents are very tech-savvy and we are invariably pleased that most have done independent research before the updates even happen!
Please elaborate a bit further on the “Circle of Listening” Method (to be published in Chapter 3 of book for Plural Publishing, Inc. in progress.) and the Hierarchy of Auditory Skills:
Susan G. Allen: There are several resources for the hierarchy of auditory skills; it is essential that the practitioner understands the continuum of listening skills along a normal developmental pattern. The “circle of listening” (Allen 2008, 2003) is a method of learning to listen which is an expansion of the “auditory sandwich” as referred to by Koch (1999). It’s all about listening: the circle of listening facilitates learning.
As you look at Figure 1, you will see that the circle of listening begins with the original auditory-only presentation of the auditory stimulus which is pictured by the stop sign. The child is presented with the language on the individual child’s language level. This utterance could be a syllable (e.g., /ba/,) a vocabulary word (e.g., more,) a language structure (e.g., a big dog) or a sentence, etc. The presentation is first through auditory-only presentation in 3 different ways before using additional cues (e.g., visual)
(1) If the desired response is not achieved, the original stimulus should be repeated closer to the child’s microphone to ensure auditory attention.
(2) If the utterance is not understood, the language should be presented auditory-only using acoustic highlighting (e.g., go closer to the child’s 18-inch “bubble”, highlight key words, elongate vowels or consonants for emphasis, whisper, or any acoustic highlighting strategy, while maintaining the use of audition ONLY)
(3) If the stimulus is still not understood, remake the original into a simpler form. If the utterance is understood, immediately pair the simpler form with the ORIGINAL auditory utterance. Repeat the ORIGINAL utterance for immediate reinforcement and listen for the child’s production to be sure it matches the stimulus. Correct production will then reinforce the listening skills and complete the “loop.”
The circle of listening will reinforce Ling’s feedback/feedforward loop (Ling, 1976) to develop maximum auditory and speech skills. This method also maximizes the child’s use of audition with Allen’s 3 P’s paradigm: Perceiving, Processing, and Producing (Allen, 2008, 2003).
Using the circle, the child is more likely to comprehend AND store it in his/her memory bank for later retrieval by pairing the unknown with the known to generalize the information successfully. Also, remember to use appropriate language levels at and slightly above to pair new information with old information.
However, if the child did not comprehend the message through listening only in the three different ways described, then, vision should be added (e.g., a developmentally appropriate manipulative, picture, written grapheme(s) or key words). Once the target is accurately achieved, then the circle is finished by returning to the auditory-only presentation. But, again, not just auditory only, but the ORIGINAL presentation so that the child will “pair” the unknown with the known, understand and generalize the information.
Figure 1: Circle of Listening
Share some best practices that professionals can use when coaching parents to encourage their children's "auditory feedback loop."
Shefali Shah: “Waiting” is a very versatile auditory-verbal technique. Parents observe its effectiveness first hand when it is demonstrated by the auditory-verbal therapist in a session and, once coached and guided by the professional, develop the confidence to use it effectively. I learned from my mentor about the effectiveness of “waiting” in clinical practice and explored many instances in my own practice such as: after the parent or therapist has modeled a pattern, word, phrase or sentence and the child expresses it incorrectly, waiting by both parent and therapist has demonstrated that the child will pause, reflect, recall and say it again, often with far better accuracy. This “waiting” has served as a reminder cum expectation that the child reassess what was said and monitor his/her utterances. On occasions where the child looks from parent to therapist, unsure of the expected response, the auditory-verbal technique of “cocking one’s ear” expectantly, reminds the child to recall what was said or request clarification.
“Whispering might seem to be counterintuitive when teaching a child in developing phonemes. Can you talk more about the power of whispering and why it is so important?”
Susan G. Allen: Whispering is one form of acoustic highlighting, a technique to “heighten” the audibility and awareness of specific phonemes, words, etc., and draw the child’s attention to the auditory signal. There are many strategies to use for acoustic highlighting and they are all important to help children with hearing loss to develop listening and speaking skills.
The use of whispering is very helpful when emphasizing voiceless phonemes. Even children with little hearing can discriminate between voiced and voiceless phonemes because the difference is based on timing cues of which they have access. Whispering intensifies consonant phonemes and this is a facilitative strategy when they are next to vowels since vowels carry more loudness than consonants. (Estabrooks, 2006). For example, the /g/ is less audible at the end of a word as in “dog” than it is in “doggie.” Whispering and elongating the /s/ and the /sh/ in “Sue” vs. “Shoe” helps to distinguish between the two releasing voiceless consonants. Whispering makes voiceless consonants more salient. See Estabrooks and Marlow for a detailed description presentation on the “variables influencing the type/degree of acoustic highlighting.”
When a child with hearing loss fitted with appropriate technology is not developing age-appropriate behaviors, what are some of the first questions that you ask parents to get to the bottom of the issue?
Shefali Shah: Parents are the major agents of change in their child’s listening, speech and language from the early days onwards. The LSLS coaches and guides parents to become aware of the early developmental milestones of children with typical hearing in the areas of audition, language, cognition, speech and communication in keeping with Principle 7 of auditory-verbal therapy. Every auditory-verbal session guides parents to understand and follow up on session targets in the light of typical development and to view their baby’s development accordingly. Specific and open-ended questions after a session help guide such discussion. For example: “How do you think that went? Do you think she understood that target? What makes you say so?” Parents are therefore a part of these conversations from the start and, over time, come to drive them. This becomes evident when parents begin to open the discussion with questions such as “He didn’t seem to understand that. Should he have? Don’t you think he’s too young for that right now?” Individual family situations may evoke different responses to these ongoing discussions but annual assessments (both informal and formal) help validate and direct their child’s progress. For example “Well, I think it brings us back to the point that she doesn’t have sufficient access right now. I believe she will, once she is implanted.” Or “Her device was activated six months ago; don’t you think she should have got that by now? I can’t imagine why she didn’t get that! I’ve been talking about it at home all the time!”
As the LSLS professional partners with parents, they embark on a journey of ongoing evaluation and refinement, committed to staying the course.
Give us a few examples of "handing over to the parent" in an auditory-verbal session?
Shefali Shah: The “handing over to the parent” strategy in auditory-verbal practice is as easy as it is difficult. I know that the part of me that struggled with it wanted to stay in control and yet when I let go and handed over, the bar was invariably raised.
I now hand over to parents in the very first session. Having modeled a Learning to Listen toy, such as an aeroplane for example, I hand over the aeroplane to the father who then whirls it around with amazing sound effects and talks about how it lands and takes off. It doesn’t matter whether his baby has detected the sound; what matters is that the parents have created a space in which to enjoy their baby. Listening will follow.
I remember working on a target in audition where a 3-year-old was expected to identify familiar objects by description. I handed over to the mother having done two examples and was amazed by the description she gave. She said beaming, “I’m thinking of something that we flicked yesterday!” Her daughter answered promptly “Orange seeds!” She then told me how they had shared an orange together and had had a good giggle “flicking” the seeds off their plate. I told her I couldn’t possibly compete!
To measure a child’s rate of progress, both formal and informal assessments are needed. Please give a few examples of both and tell us how you strike a balance between the two.
Susan G. Allen: Diagnostic assessment and teaching is an ongoing process and involves both formal and informal assessments to determine a child’s ability to perceive, process, and produce (Allen, 2008, 2003). The practitioner needs to determine if the child can perceive the message, process it in the brain, and produce the required response. In other words, the practitioner needs to know “where the child is in order to know where to go” (Allen, 1999). Every therapy session, every classroom lesson, every interaction between the child and caregivers should be viewed as diagnostic in order to develop and effectively judge the intervention. It is very important to have good observational skills and to be effective in administrating formal diagnostic instruments to get an accurate profile of the child’s strengths and weaknesses. The use of formal and informal instruments is critical to obtain baseline data on auditory, speech and language goals, to determine an appropriate management plan, and to monitor progress. The ultimate goal is for the child to make appropriate progress and to reach performance at and above his/her chronological age so that he/she can be mainstreamed alongside their peers with typical hearing successfully.
To measure how the child with hearing loss is progressing, formal and informal tests used with children with typical hearing need to be used with children with hearing loss. For example, to measure functional speech perception skills, one may use a more formal speech perception test (e.g., APT/HI-R, Auditory Perception test for the Hearing Impaired-Revised) and an informal listening skills checklist (e.g., The Checklist of Auditory Communications Skills, Nancy Caleffe-Schenck and Darla Franz). Another example, to measure speech production, one could choose the Goldman Fristoe Test of Articulation or a normed speech development chart. For a formal language instrument one could pick the PLS-4 Preschool Language Skills or an informal measure of children’s behaviors at different levels (e.g., It-MAIS). There are many formal and informal measures from which to choose. The important thing to remember is that the practitioner(s) needs objective data to compare the child with hearing loss to a child with typical hearing to mainstream effectively, to communicate to families and other professionals, and to judge the child’s progress toward the families’ goals.
In summary, to provide appropriate intervention, the practitioner needs to develop a profile of the child’s current speech perception, speech production, and language abilities using formal and informal measures. These assessments will determine if the child is perceiving, processing, and producing (Allen, 2003) and helps to locate where a problem occurs if there is a delay in the development of skills. Ongoing diagnostic auditory-verbal sessions help to answer key questions and guide practice. (Perigoe, Allen, and Dodson, in 101 Frequently Asked Questions About Auditory-Verbal Practice, 2012.)
LSL professionals prepare both parents and children with hearing loss for participation in their community of choice. How do you get ready as a professional to do that?
Shefali Shah: From a personal point of view, when I’m out and about, I’m always listening to what children with typical hearing are talking about, playing, singing, wearing, enjoying and even what they don’t enjoy and what the latest “cool” language in circulation is. I also am attentive to what parents talk to their children about while I stand in queues or am out in public places. I like to think that it’s only because I am an LSLS professional but my family reminds me that I am guilty of overhearing!! I then try to incorporate these into the activities for my sessions, cross-matching for age and current levels of functioning. I have woven songs, bay-blades, the latest color in nail polish and the most popular jingle on television into session targets several times!! They also make great session openers! I often ask parents for help to stay abreast. For example a question such as “Can you help me remember the second verse in this song/rhyme that goes….?”
I coach parents to be mobile with their baby from the early days. We discuss how to handle baby at the market, at the park and how to set up that first play date. I’m always asking about the families with children the same age, near where they live and whether their children play together. Once this exchange is initiated, parents often take the initiative to lead discussions on how to facilitate their child being a part of the group at school, the circle at home, play with cousins, and share their pain when some of these events end with disappointment. Parents are guided to learn early that their child can be as much a part of their communities of choice as they choose.
Susan G. Allen: From an academic point of view, to prepare as a professional to serve both parents and children with hearing loss with the goal of participating in their community of choice, the professional needs to be informed about hearing loss, options for communication, and the data regarding outcomes of their choice of communication. Then, if the goal is for preparing their child for the hearing world, then the family needs a professional who listens well and who is well trained in the 9 Listening and Spoken Language Specialist (LSLS) Domains of Knowledge (hearing and hearing technology; auditory functioning; spoken language communication; child development; parent guidance, education and support; strategies for listening and spoken language development; the history, philosophy and professional issues; education; and emergent literacy). See the AG Bell Academy for details on LSLS development.
The formation of the LSLS Academy was a giant step towards preparing competent professionals and certifying them for preparing children and families. I enjoyed playing a very small part in that role for many years…always striving for a way to ensure that competent professionals who guided parents well and who could teach a deaf child to learn to listen and speak were able to do so and would be recognized by such a valuable professional organization as the AG Bell Academy. Thanks to so many dedicated professionals, I could not begin to mention all of them here, but to whom I am very grateful for their efforts (spearheaded by Carol Flexer, Don Goldberg, and Theresa Caraway).
For more information on how to work with parents of children with hearing loss, see FAQ #49 in AG Bell’s newest publication, 101 FAQs About Auditory-Verbal Practice. The book is a comprehensive collection in which renowned experts from the field of auditory-verbal practice take both parents and professionals on a journey through current theory, practice, and outcomes.
101 FAQs is a must-have tool for the families of children who are deaf and hard of hearing and the professionals that work with them to develop their full potential!
To learn more about this and the answers to a 100 other frequently asked questions about auditory-verbal practice, visit ListeningandSpokenLanguage.org/101FAQs and order your print or e-book copy today! And don’t forget to let us know your feedback on the book!
Allen, S. G. (2008). Auditory Perception Test for the Hearing Impaired–Revised (APT/HI-R). San Diego, Calif.: Plural Publishing, Inc.
Allen, S.G. (2004, June). We’re listening and talking: Treating deaf children with additional complications. Short course presented at the 2004 Convention of the Alexander Gra¬ham Bell Association for the Deaf and Hard of Hearing, Anaheim, Calif.
Allen, Susan G. (2003). Learning to listen ~ listening to learn: auditory perception-developmentally appropriate goals and techniques for working with deaf and hard of hearing children. Kissimmee, Fla.: Osceola County Schools Day Workshop.
Allen, S.G. (2003). Listen up! Learning to listen ~ listening to learn. Philadelphia, Pa.: Children’s Hospital of Philadelphia.
Allen, S.G., Bartlett, C., Cohen. N.L., Epstein, S., Hanin, L., & Treni, K. (1999, November): Maximizing Auditory and Speech Potential for Deaf and Hard of Hearing Children: Proceedings of a Clinical Roundtable. Pediatric News (Suppl.), 3-14.
Estabrooks, W. (2006). Auditory-Verbal Therapy and Practice. Washington, D.C.: A.G. Bell Association for the Deaf and Hard of Hearing.
Perigoe, C., Allen, S. G., & Dodson, C. (2012). Why is diagnostic work important in auditory-verbal therapy and education? In W. Estabrooks, 101 Frequently Asked Questions About Auditory-Verbal Practice, 382-387. Washington, D.C.: Alexander Graham Bell Association for the Deaf and Hard of Hearing
Zimmerman-Phillips, S., Osberger, M. F., & Robbins, A. M. (1997). Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS). Sylmar, Calif.: Advanced Bionics.