AUDIOLOGY AND SPEECH LANGUAGE PATHOLOGY

1. Aural rehabilitation
SUBMITTED TO: MS. DEEPIKA J
SUBMITTED BY: SUCHISMITA MISHRA

2. • Aural rehabilitation is the process of identifying and diagnosing a hearing loss,
providing different types of therapies to clients who are hard of hearing, and
implementing different amplification devices to aid the client’s hearing abilities.
• Aural rehab includes specific procedures in which each therapy and amplification
device has as its goal the habilitation or rehabilitation of persons to overcome the
handicap (disability) caused by a hearing impairment or deafness.
• Aural rehabilitation is frequently used as an integral component in the overall
management of individuals with hearing loss and refers to services and
procedures for facilitating adequate receptive and expressive communication in
individuals with hearing differences.
• Aural rehabilitation is often an interdisciplinary endeavor involving physicians,
audiologists and speech-language pathologists

3. Scope of practice
• Audiologists and speech-language pathologists are professionals who typically
provide aural rehabilitation components.
• The audiologist may be responsible for the fitting, dispensing and management of
a hearing device, counseling the client about his or her hearing loss, the
application of certain processes to enhance communication, and the skills
training regarding environmental modifications which will facilitate the
development of receptive and expressive communication.
• The speech language pathologist is typically responsible for evaluating the client’s
receptive and expressive communication skills and providing the services to
anchor improvement.
• The speech-language pathologist also provides training and treatment for
communication strategies, speech-perception training (e.g., speechreading,
auditory training and auditory-visual-speech-perception training), speech and
voice production, and comprehension of oral, written, and sign language.

4. Types of aural rehabilitation therapies
Hearing aid orientation:
The process of providing education and therapies to persons (individual or group)
and their families about the use and expectations of wearing hearing aids to
improve communication.
Listening strategies:
The process of teaching hard of hearing persons common and alternative
strategies when listening with or without amplification to improve their
communication.
Speechreading:
The process of using or teaching the understanding communication using visual
cues observed from the speaker’s mouth, facial expressions, and hand movements.

5. Auditory Training:
The process of teaching an individual with a hearing loss the ability to recognize
speech sounds, patterns, words, phrases, or sentences via audition.
Uni-sensory:
Therapy philosophy that centers on extreme development of a single sense for
improving communication.
Cued speech:
The process of using and teaching manual hand or facial movements used to
supplement an auditory-verbal approach to the development of communication
competence.

6. Total communication:
The process of using and teaching speech, language, and
communication skills simultaneously using manual communication,
speech, and hearing.
Manual communication:
The process of using and teaching communication via finger-spelling
and with a sign language.

7. General steps included in the aural rehab of a
child (infant, toddler, child)
• 1. Identification of Hearing loss
• 2. Audiological evaluation
• 3. Hearing aid and or assistive listening device evaluation and use
• 4. Parental guidance to select appropriate therapy program
• 5. Early intervention program
• 6. Communication skill development (auditory, speech/language,
sign)
• 7. Literacy development (cognition, writing, reading)

8. Regardless of treatment method for an infant, toddler, or child, the
following problems have to be considered:
• 1. Perceptual problems
• 2. Communication problems (aural, oral, manual)
• 3. Literacy problems (cognitive, memory, dexterity)
• 4. Social, emotional, psychological problems
• 5. Education and vocational placement problems
• 6. Family and societal problems

9. General steps included in an aural rehab
program for an adult
• Adult programs differ from child programs because adults typically
have a later onset of significant hearing loss; they have acquired a
worldly knowledge, and have experienced normal speech/language
development. Consequently, treatment and therapy strategies are
much different compared with a child.

10. • 1. Assessment and impact of hearing loss
• 2. Assessment for the use of hearing aids and or assistive listening
devices
• 3. Assessment of listening strategies and speech reading skills
• 4. Developing a treatment program including the family
• 5. Delivery of the treatment program
• 6. Outcome measures

11. Treatment strategies for adults center on:
• Hearing aid and or assistive listening device evaluation and
orientation
• Providing therapy to maintain speech and language
• Providing therapy to increase listening strategies and speech reading
• Counseling to facilitate adjustment to hearing aid and or assistive
listening device and possible psychological, emotional, and
occupation impacts of hearing loss.

12. Regardless of whether the aural rehab program is designed for a child
or an adult, the members of the hearing care team are the same. The
principal members are the audiologist, speech-language pathologist,
otologist, and the family physician.
Additional members of the hearing care team can include any of the
following: educators of the child who is hard of hearing, has mental
health counselors, school psychologists, sensory device manufacturers
and distributors, social workers, telecommunication and captioning
service providers , and vocational counsellors.

13. Level 0 Unaware of environmental sounds
Level 1 Detects some environmental sounds
Level 2 Responds to some speech sounds
Level 3 Can identify some environmental sounds
Level 4 Understands some spoken words with additional performatives e.g.
‘where is the duck that says quack quack’, ‘give me the car brmm’
Level 5 Understands common phrases e.g. pick it up; it’s bath time .
Level 6 Understands some spoken words without performatives e.g. give me
the
duck’/ ‘go get the car’
Level 7 Responds appropriately to simple questions e.g. what is it?
Level 8 Understands conversations with familiar speakers
Level 9 Understands conversations with unfamiliar speakers
Level 10 Follows recorded stories
Level 11 Uses the telephone with familiar speakers
REVISED CAP (Categories of Auditory Perception) Scales:
The Shepherd Centre’s revised version, based on Nottingham CI
Program, 1995

14. Oral Language Development from Infancy to
Preschool
• Oral language development includes critical skills that let children
(1) communicate—listen and respond when other people are talking.
(2) understand the meaning of a large number of words and concepts
that they hear or read.
(3) obtain new information about things they want to learn about, and
(4) express their own ideas and thoughts using specific language.

15. Shared Conversations: Talking with Children
• Caregivers can do more intentionally to build children’s oral language
development.
• They can help children build language skills both through their own
language interactions with children and by setting up an environment that
gives children lots of reasons to talk and things to talk about.
• One of the best ways that caregivers can help children develop their oral
language skills is through shared conversations with them. Shared
storybook reading provides an especially good platform for conversations
with children.
• These language interactions are the basis for building children’s
understanding of the meaning of a large number of words, which is a
crucial ingredient in their later ability to comprehend what they read.

16. How Adults Talk with Children Matters
• HOW caregivers talk with children is important. To help children
develop strong oral language skills, it’s important for caregivers to be
sure that their language interactions are the kinds that give children
practice with the following things:
• 1. Hearing and using rich and abstract vocabulary
• 2. Hearing and using increasingly complex sentences
• 3. Using words to express ideas and to ask questions about things
they don’t understand
• 4. Using words to answer questions about things that are not just in
the here-and-now

17. • TURN-TAKING. The richest talk involves many “back-and-forth” turns
in which the provider builds on and connects with the child’s
statements, questions and responses.
• ONE-ON-ONE. Talking one-on-one gives the provider a chance to
repeat (say back), extend (add to), and revise (recast or restate) what
children say. Children have a chance to hear their own ideas reflected
back.
• DESCRIPTION. Narrating children’s activities is a way for caregivers to
not only introduce new vocabulary but also encourages deeper
understanding of new words so they can begin to define and explain
the meaning of these words.

18. • SUPPORTING CHILDREN’S UNDERSTANDING OF THE MEANING OF
MANY WORDS
Use rich vocabulary and support children in developing a deep
understanding of the meaning of words—providing multiple definitions
and examples, connecting new words with concepts children already
know.

19. Children need reasons to talk and interesting
things to talk about
• Think about the “talk times” during the day. Caregivers spend a lot of
time talking to and with children about rules and schedules .
• PERSONAL CONTENT
• STORY TELLING
• NEW INFORMATION
• PLAY
• EXTENDED CONVERSATION
• MODELING LANGUAGE

20. Reading with children is an opportunity for
conversation.
• Sharing stories helps children build oral language in a variety of
ways—developing children’s speaking and listening skills, introducing
new concepts or information, and increasing both vocabulary and the
ability to define and explain the meanings of new words.

21. Make shared reading more powerful in
building oral language
• READ WITH A SMALL GROUP Shared reading is most effective when
done with a small group of 1 - 3 children. This usually allows the
caregiver to draw each child into the book through questions and
conversation about the pictures and plot.

22. • FOCUS ON VOCABULARY Caregivers pick books that include new
words and ideas and explicitly call attention to the new and
interesting vocabulary words in books that intentionally help children
understand the core meanings of words.
• Tell the child what the word means.
• Point to a picture in the book that illustrates the word.
• Connect the new word to words the child already knows.
• Give examples of the word.
• Encourage the child to use new words in conversations.

23. • EMPHASIZE THE USE OF ABSTRACT LANGUAGE Caregivers encourage
children to use language to communicate thinking about things that
they cannot actually see in the books. Ask children to use language to
talk about things that might happen in the story that they haven’t yet
read about, or things that could happen. Children should be
encouraged to use language to express their imagination and ideas.
• Ask children to predict what might happen in the story.
• Ask children to imagine what characters in the story might be
thinking or feeling.
• Ask questions that require the child to use language to analyze the
meaning of what is happening in the book.

24. • ASK QUESTIONS AND ENCOURAGE DISCUSSION
• During shared reading, ask questions about the pictures and story to encourage children
to use language, including abstract language.
• Ask younger children to label pictures: “Do you remember what this animal’s name is?”
• Ask younger children to describe details of the pictures or story: “How is the fire engine
getting to the people at the top of the building?”
• When they have had practice with a story, ask the child to recall something about the
story: “Can you tell me what happened to Isabella the night before?”
• Ask an older child to predict what’s going to happen in the story: “What do you think is
going to be there in the morning when Peter looks in his pocket for the snowball?”
• Ask an older child to imagine events beyond the story: “If you lived in the desert, what
kind of house would you build?”
For older children, book discussions should encourage children to think—to predict, draw
conclusions about why characters act or feel the way they do.

25. • READ STORIES MORE THAN ONCE Take advantage of the fact that
children have favorite books, and they quickly learn what happens in
the story and are eager to talk about what they know. Use repeated
readings to extend conversations about the story.
• Children can answer questions about the story—who, where, what,
why, how many, how much, how long, and how far.
• With some prompting, they can connect stories to their own real
life experiences.

26. • BUILD ON THEMES Pick out books that are about the same theme, such as
“under the sea” or “the rain forest,” including non-fiction or expository
books.
• Reading several books on the same theme gives children a shared topic
for extended, rich conversations.
• Conversations about a theme provide opportunities for the provider to
“recycle” vocabulary—use the new theme-based words and encourage
children to use them. This helps children remember the new words and
deepens their understanding of the meanings of the words.
• Theme-related activities, such as constructing a mural that shows
different fish and coral, further encourage children to use and learn the
new language from the books that have been read together.

27. Talking with Children Makes a Difference
• The more that caregivers intentionally make time for talking and sharing
experiences such as…
• • extended, contextualized conversations with individual children
• • reading books with interesting and rich concepts
• • engaging children in discussions and questions about the book
• • modeling speaking in complete sentences in questions, responses, and
statements
• • providing opportunities for children to talk about things and events that
are not in the here-and-now—past, present, and imaginary
…the more support there is for children’s language development and later
reading comprehension success.

28. Quick Reference Guide
• LITERACY. All the activities involved in speaking, listening, reading,
writing and appreciating both spoken and written language.
• EARLY LITERACY SKILLS. Skills that begin to develop in the preschool
years, such as alphabet knowledge, phonological awareness, writing
name, print knowledge, and oral language. Research has shown that
these skills may provide a foundation for later-developing, more
mature reading and writing skills.
• ORAL LANGUAGE DEVELOPMENT. The development of knowledge
and skills that allow children to understand, speak, and use words to
communicate.

29. • Speaking skills
• Producing the sounds of language
• Understanding what words mean and the connections among words
• Using words conventionally—for example, to put together words in the
right order
• Using conventional forms of words, for example, plurals and appropriate
forms of verbs to indicate things that happened in the past or might
happen in the future
• Using language for different purposes—to express ideas and feelings, to
obtain or communicate information, to negotiate social disagreements, etc.

30. Listening skills
Understanding what other people are saying when they speak
Detecting, manipulating, or analyzing the auditory aspects of spoken
language Enjoying listening to stories
Following oral instructions

31. Communication skills—for talking and listening
Understanding the social rules of conversation—taking turns,
listening when someone else is talking
Understanding and using the rules of grammar
Asking questions to get information
Engaging peers and adults

32. Vocabulary skills—for talking, listening, and conversation
Understanding a large collection of words and their meanings
Understanding the inter-relationship among words—for example,
subordinate and super-ordinate words (e.g., dogs and cats are both
types of animals)
Extending own vocabulary to create new meaning

33. REHABILITATION MANAGEMEN

34. • 1. Counseling, which focuses on identifying, understanding, and shaping the
attitudes and goals that influence help seeking, decision making, and action
taking, with an emphasis on the factors that predispose, enable, and reinforce
individuals in their adjustment to hearing difficulties and associated stresses. The
audiologist gives the client information based on the results of the assessment
and the available evidence regarding specific treatment options. Through an
interactive process with the client, goals are set to address needs at three levels:
audibility, activity, and participation.
• 2. Audibility and instrumental interventions, in which hearing aids, cochlea
implants, and/or various types of HAT are discussed, selected, and fitted, with
provision of pre- and posttrial education to ensure the effective use of these
technologies. This level of intervention addresses amplification issues in terms of
the fit and function of devices and orientation to them.

35. • 3. Remediation for communication activities, which focuses on changing
behaviors that will contribute to enhancing the communication performance of
listeners with their communication partners in hearing-demanding activities and
environments, including when and how to use devices and other strategies.
Building self-efficacy and counteracting stigma may be a prerequisite to changing
specific target behaviors.
• 4. Environmental coordination and participation improvement, with an emphasis
on the social and physical supports (in the health care system, the community,
and occupational, educational, and/ or family contexts) are required to ensure
that rehabilitation achieves the individual’s goals for participation in everyday life,
especially in the priority situations that are targeted in the client-specific goals for
rehabilitation.

37. Counseling and Psychosocial Considerations
with a Health-Promoting Approach
• Communication Goals and Style.
• Stereotypes and Adjustment.
• Coping.
• Setting Objectives.

38. Amplification and Instrumental Interventions
to Achieve Audibility
• Is the Client Ready for an Instrument?
• Fit and Function of the Instrument.
• Modifying Procedures for Older Adults.
• Binaural Fitting.
• Special Device Features.
• Extra Adjustment Time: Outcome Measures.
• Orientation to Instruments.
• Individual Orientation.
• Orientation in Groups.
• The Significant Other.
• Advocacy in Restrictive Environments or Residential Care.
• Alternative Media.

39. Remediation for Communication Activities
“Bridge” Therapy
• Individual speechreading instruction was deemed appropriate for a 62-year-old woman who had
suffered loss of hearing in one ear due to Ménière’s disease.
• Socially active in the community and reluctant to disclose her loss to others, the woman
preferred the privacy of individual therapy.
• She was an avid bridge player, and participation in her bridge club was of utmost importance to
her.
• To address her single goal of retaining excellent ability to participate in bridge games, individual
therapy activities were chosen that satisfied the same five ingredients described earlier for a
good group meeting.
• One such therapy activity consisted of “playing” bridge through a two-way mirror with only visual
cues for statements, such as “I bid three spades,” “I pass,” and so forth.
• The woman improved her ability to speechread the language of her favorite game. This proved
fortuitous since the signs of Ménière’s syndrome (roaring tinnitus, vertigo, and nausea) signaled
the eventual loss of hearing in her good ear.
• As her hearing loss continued to deteriorate, additional goals were formulated and therapy
activities undertaken.

40. • Conversational Therapy and Tactics.
• Partner Communication.
• Simulations and Role Playing.
• Empathy and Listening.

41. Environmental Interventions to Improve
Participation
• Participation in Situations and Relationships.
• Social Environmental Supports.
• Physical Environmental Supports.

42. OTHER IMPORTANT ISSUES IN THE SCOPE OF
AR PRACTICE
Vestibular Rehabilitation Therapy
• The goal of Vestibular Rehabilitation Therapy (VRT) is to improve balance
and gait by retraining the sensory/motor systems described above. Those
who respond well to VRT usually have chronic conditions of motion-
provoked dizziness or generalized disequilibrium. Individuals with benign
paroxysmal positional vertigo (BPPV), asymmetrical vestibular disorders, or
abnormal postural control or gait problems are typically good candidates.
• In addition, people who have demonstrated difficulties integrating visual,
vestibular, or somatosensory input as verified by CDP or during clinical
evaluations can benefit from VRT. In contrast, people experiencing
progressive medical pathologies that involve balance or severe disability
may not realize the same level of improvement.

43. Tinnitus Management
• Tinnitus Retraining Therapy (TRT) conditions the patient not to respond
emotionally to tinnitus.
• Habituation can be defined as a disappearance in reactions induced by a
stimulus through devices.
• Some technologies have advanced the research investigating the
mechanisms involved in tinnitus. For example, one treatment of tinnitus is
transcranial magnetic stimulation (TMS) (Dornhoffer & Mennemeier, 2010).
• Cognitive behavioral therapy (CBT) is another psychological approach that
has been used successfully to treat tinnitus. It is based on the assumption
that the thoughts we have learned over time have a great deal to do with
our feelings and subsequent behaviors.

44. Listening and Spoken Language Strategy:

45. Acoustic Highlighting
Definition: Acoustic Highlighting is an added vocal emphasis on an identified
target. A target can be important sounds, words, parts of phrases, or
grammatical structures in a sentence.
• attention to auditory signal and/or speaker
• responses from child
• turn-taking skills
• expressive language

46. Ask “What did you hear?”
Definition: When a child gives an incorrect or inappropriate response,
no response, or experiences a communication breakdown, the adult
can ask, “What did you hear?” to prompt the child to give back the part
of the message that was heard and attempt to repair the breakdown.
• attention to auditory signal and/or speaker
• confidence in listening skills
• repair strategies for communication breakdowns

47. Auditory Bombardment
Definition: Auditory Bombardment provides numerous opportunities for a
child to hear the target phoneme, sound or language (Dickson, 2010).
• attention to sound
• awareness of sound
• integration of listening into a child’s personality
• comprehension through listening (Simser via firstyears.org, January 2013)
• proper articulation of speech sounds

48. Auditory Closure
Definition: Auditory Closure is when a speaker begins a song, rhyme, or
sentence and then stops talking in order to encourage the child to fill in
a verbal response.
• attention to speaker
• response from child
• turn--‐taking skills
• Child’s use of spontaneous language
• expressive language expansion

49. Auditory First
Definition: Auditory First is an attitude as well as a set of conditions
that will enable the child to have better access to speech and language.
• self--‐advocacy skills for hearing equipment
• attention to auditory signal first and foremost
• a mindset of listening in the parent and child
• integration of listening into the child’s personality et. al, 1997)

50. Auditory Sandwich
Definition: Through the use of the Auditory Sandwich, information is
presented through listening before the introduction of visual or other
support information is given to a child. When visual information is needed to
assist in comprehension, the information is then put back in to the auditory
only presentation. The Auditory Sandwich is also referred to as the Listening
Sandwich.
• suprasegmentals of speech
• attention to auditory input and the speaker
• Parents’ belief that child is able to gain information through listening alone
• ability to process language through audition

51. Expectant Look
Definition: The Expectant Look is a non--‐verbal signal given to a child
to indicate a response is expected.
• attention to speaker
• response from child
• turn--‐taking skills
• expressive language expansion

52. Expansion
Definition: To expand, an adult repeats back what the child has said and
either adds something new, or corrects syntax or grammatical
structure.
• length of utterances (Cole & Flexer, 2007)
• degree of syntactic or semantic correctness
• complexity of responses from child
• auditory feedback loop

53. Joint Attention
Definition: Joint Attention is the ability for two or more people to share
a common focus (Woods & Wetherby, 2008).
• attention to auditory input: When joint attention is established, the
child is In the proper position for auditory only input as child’s gaze is
on an object or an activity and not the face of the speaker.
• build social cognition (Mundy & Newell, 2007)
• assist development of theory of mind (Gavrilov et al., 2012)
• increase language development (Brooks & Meltzoff, 2005)

54. Model Language
Definition: To model language for a child who is deaf or hard of hearing, an
adult speaks clearly at all times, uses the correct grammar, and gives
appropriate and meaningful language in context.
• neural connections in the brain (Suskind & Suskind, 2015)
• auditory feedback loop
• receptive language skills
• expressive language skills
• appropriate grammatical rules

55. Motherese
Definition: Motherese is the singsong voice that parents naturally use when
speaking to very young babies. Motherese is also referred to as parentese, baby
talk, or child directed speech.
• attention to speaker
• repertoire of vowel sounds
• cooing
• response from child
• social--‐emotional development of baby (Bergeson--‐Dana, 2012)
• turn--‐taking skills

56. Open-Ended Questions
Definition: Open-ended questions are questions that require more than
a yes/no or one word response (Bond & Wasik, 2009).
• attention to auditory information
• length of utterance
• turn taking during discussion

57. Optimal Position
Definition: Proper position and distance between the speaker and the
listener which enables the child with hearing loss to have the most
optimal access to spoken language through audition.
• auditory attention to speaker
• responses from child
• access to subtle conversational cues, faint or distant speech

58. Repetition
Definition: Repetition is an indirect or informal language stimulation technique
where a targeted sound, word, phrase or sentence is said more than one time
(Weybright, 1984).
• auditory feedback loop
• receptive language
• ability to follow commands when the child is given another chance to hear
• previously stated information
• expressive language
• knowledge of proper grammatical structures

59. Sabotage
Definition: Sabotage creates an unusual or unexpected situation with
familiar items or routines which is contrary to the child’s expectation or
understanding (Winkelkotter & Srinivasan, 2012).
• joint attention
• attention to auditory information
• length of utterance
• opportunities to practice using spoken language

60. Self Talk/Parallel Talk
Definition: Self--‐Talk and Parallel Talk are indirect language stimulation techniques
that do not require a response from the child.
Self--‐Talk: an adult talks to the child about what the adult sees, does, or hears at
any particular moment in time.
Parallel Talk: an adult talks to the child about what the child does, hears or sees at
any particular moment in time
• Parents’ ability to interact with their child
• receptive language
• expressive language
• ability to use grammatically correct structures
• conversational skills (Raver et al, 2012)

61. Take Turns
Definition: In order to take turns, adults learn to encourage a back and
forth volley between themselves and the child.
• auditory attention to speaker
• response from child
• conversational competency
• expressive language skills

62. Wait Time
Definition: Wait time is the pause used between an adult’s interaction
with a child and the child’s response that allows the child to process
the auditory information and formulate a response (Dickson, 2010).
• length of a response
• Speaker’s confidence
• likelihood of a response from child
• communicative intent
• turn--‐taking skills (Cole & Flexer, 2007)

63. Whisper
Definition: A Whisper is accomplished when the speaker turns off the
voice and reduces the suprasegmental of intensity. Whispering is a
form of acoustic highlighting.
• auditory attention
• auditory accessibility
• auditory feedback loop