Is Auditory-Verbal Practice an Effective Intervention Approach?

By Elizabeth Fitzpatrick, Ph.D., LSLS Cert. AVT, Ellen A. Rhoades, Ed.S., LSLS Cert. AVT,
Dimity Dornan, Ph.D., LSLS Cert. AVT,
Ellen Thomas, M.A., CCC-SLP, LSLS Cert. AVT 
and Donald M. Goldberg, Ph.D., CCC-SLP/A, FAAA, LSLS Cert. AVT

The world of health care, including (re)habilitation, has changed substantially since auditory-verbal practice was first promoted as an intervention for children with hearing loss. Like most facets of health care, thinking and practice have been shaped by the evidence-based medicine movement (Guyatt, 1991). In the early years of auditory-verbal practice, case reports, therapy demonstrations, and clinical and educational information on how to teach children with hearing loss dominated scholarly activities and seemed to be sufficient for clinicians, decision makers, and consumers. In the last decade, against the backdrop of evidence-based medicine, there has been a growing awareness of the need to assemble scientific information to document that auditory-verbal practice is effective.

The purpose of auditory-verbal practice has not changed since its inception—and remains to develop spoken language in children with hearing loss so that they can be included in typical learning and living environments (Estabrooks, 2006). One of the challenges in assembling outcome-related evidence is that despite the lack of change in the overall goal of auditory-verbal practice, the definition of expected or desired outcomes for children in auditory-verbal programs has changed dramatically, particularly for children with severe-to-profound hearing loss. Outcomes have been redefined mainly due to the hearing technology of cochlear implants and earlier access to hearing due to universal newborn hearing screening in many countries. Therefore, even though earlier goals included spoken language and intelligible speech, it is now expected that spoken language skills meet age-appropriate levels.

Evidence for Auditory-Verbal Practice

Although evidence-based care is now mature in many health care fields, other fields—such as pediatric hearing loss (re)habilitation—have been slower to embrace the movement. One of the greatest difficulties in demonstrating the effectiveness of auditory-verbal practice is in conducting controlled studies, in which a sufficiently large number of children in auditory-verbal programs are compared with groups of children who are similar but enrolled in other intervention approaches. These concerns have been well documented in several reviews of evidence supporting auditory-verbal practice and have been aptly highlighted by investigators concerned with hearing loss (Marschark, Rhoten, & Fabich, 2007; Spencer & Marschark, 2010). Unlike other areas of medicine, these professions ethically do not promote withholding certain interventions or randomly assigning children to interventions in the interest of comparing intervention methods. Therefore, scholars have rightly challenged conclusions that have often been based on lower levels of evidence, such as expert opinion and case studies. As noted by Marschark and colleagues (2007), there are considerable theoretical and practical issues that result in research addressing only part of the story in pediatric hearing loss.

In recent years, researchers have made considerable efforts to examine the effectiveness of  auditory-verbal practice. A systematic review was undertaken by Health Canada to inform recommendations for intervention in the context of the implementation of population-based screening in Canada. The purpose was to synthesize the evidence on the effectiveness of four intervention approaches: auditory-verbal, auditory-oral, Total Communication, and American Sign Language. Of the 194 papers meeting the review inclusion criteria, only one randomized controlled trial (RCT) was identified, and the majority of the remaining publications concerned cohort designs with or without some form of control group. The review concluded that there was inconclusive evidence supporting auditory-verbal or other approaches in developing positive outcomes in children with hearing loss (Schachter et al., 2002). The review was conducted from 2001 to 2002 and, therefore, included relatively few studies where children benefited from screening and cochlear implants.

It is important to differentiate between the effectiveness of auditory-verbal intervention, implying a comparison of outcomes with other intervention practices, and the results (e.g., listening and spoken language) attained by individuals enrolled in a given intervention. Although there is weak empirical evidence for the effectiveness of auditory-verbal practice when compared with other approaches, the past decade has yielded an impressive number of studies that have contributed to a better understanding of auditory-verbal outcomes. Several published reviews provide useful summaries of the available evidence through 2007 (Dornan, Hickson, Murdoch, & Houston, 2008; Eriks-Brophy, 2004; Rhoades, 2006; Schachter et al., 2002). These authors concluded that although auditory-verbal studies were limited in number and were characterized by the problems described above, there was evidence that many children in auditory-verbal programs developed listening and spoken language skills that were comparable to those of their peers with typical hearing.

The studies reviewed were conducted before the widespread implementation of universal newborn hearing screening (UNHS), and older study participants did not have access to early cochlear implantation. The single largest cohort study consisted of 40 children who received auditory-verbal intervention in a single auditory-verbal program (Rhoades & Chisholm, 2001). Their findings demonstrated that the rate of language growth for the majority of the children in auditory-verbal intervention was comparable to that of peers with typical hearing and that most were able to close
the language gap with their peers. Also of note is a survey of 114 adolescents and adults at an average age of 28.9 years (range = 18–56 years) who had graduated from auditory-verbal programs in the United States and Canada. The survey documented that 91.1% of those individuals attended mainstreamed programs in high school and that the majority (76%) of individuals reported that they continued to use spoken language and functioned primarily in environments with individuals who had typical hearing (Goldberg & Flexer, 2001). The most recent cohort study was conducted in Australia, where a cohort of 29 children was followed longitudinally in one auditory-verbal program at several regional centers. The last published data for 19 of these children, who were followed for 50 months, indicated that children progressed on most measures at a rate similar to that of their peers with typical hearing and attained speech and language scores comparable to those of their peers (Dornan, Hickson, Murdoch, Houston, & Constantinescu, 2010).

These reviews highlight the state of evidence in support of auditory-verbal practice, and all authors have called for more evidence-based research to support auditory-verbal intervention as an option for children with hearing loss.

All researchers agree that there has been a change in the landscape for children who are deaf and hard of hearing. Coinciding with the implementation of UNHS, there have been tremendous advances in the development and implementation of hearing sensory technology, including hearing aids, cochlear implants, FM systems, and other hearing devices. In tandem with the availability of high-quality auditory-verbal services to families and their children with hearing loss, researchers have made vigorous efforts to establish a body of research evidence regarding the effectiveness of auditory-verbal practice. More research, of course, is needed so that future generations of children
who are deaf and hard of hearing will continue to have exemplary listening, talking,
academic, and social skills.

To learn more about evidence-based outcomes of auditory-verbal practice, see AG Bell’s newest publication, 101 FAQs About Auditory-Verbal Practice. Listening and spoken language professionals, this is the resource you need! The book is a comprehensive collection in which renowned experts from the field of auditory-verbal practice take professionals and parents on a journey through current theory, practice, and outcomes. 101 FAQs

Visit and order your print or e-book copy today! And don’t forget to let us know your feedback on the book!

Selected References:

Dornan, D., Hickson, L., Murdoch, B., & Houston, T. (2007). Outcomes of an auditory-verbal program for children with hearing loss: A comparative study with a matched group of children with normal hearing. The Volta Review, 107, 37–54.

Dornan, D., Hickson, L., Murdoch, B., Houston, T., & Constantinescu, G. (2010). Is auditoryverbal therapy effective for children with hearing loss? The Volta Review, 110, 361–387.

Eriks-Brophy, A. (2004). Outcomes of auditory-verbal therapy: A review of the evidence and a call for action. The Volta Review, 104, 21–35.

Goldberg, D., & Flexer, C. (2001). Auditory-verbal graduates: Outcome survey of clinical efficacy. Journal of the American Academy of Audiology, 12, 406–414.

Marschark, M., Rhoten, C., & Fabich, M. (2007). Effects of cochlear implants on children’s reading and academic achievement. Journal of Deaf Studies and Deaf Education, 12, 269–282. doi:10.1093/deafed/enm013

Rhoades, E. A. (2006). Research outcomes of auditory-verbal intervention: Is the approach justifi ed? Deafness and Education International, 8, 125–143. doi:10.1002/dei.197

Rhoades, E. A. (2001). Language progress with an auditory-verbal approach for young children with hearing loss. International Pediatrics, 16, 41–47.

Schachter, H. M., Clifford, T. J., Fitzpatrick, E., Eatmon, S., MacKay, M., Showler, A., . . . Moher, D. (2002). Systematic Review of Interventions for Hearing Loss in Children. Ottawa, Ontario, Canada: Health Canada.

Spencer, P., & Marschark, M. (2010). Evidence-based Practice in Educating Deaf and Hard-of-hearing Students. New York, NY: Oxford University Press.


101 FAQs About Auditory-Verbal Practice © 2012 Alexander Graham Bell Association for the Deaf and Hard of Hearing. All Rights Reserved.