University of Edinburgh

Cochlear Implant Update

Presented on Thursday, 12 May 2011

Jane Gallacher, Advanced Rehabilitation Advisor
Scottish Cochlear Implant Programme

Paediatric Rehabilitation Techniques

Current techniques in cochlear implant rehabilitation including Auditory Verbal Therapy

CI Role in Rehab

  • Monitoring
  • Assessment
  • Advice
  • See each child for 5 years post-implant
  • Focusing on the early years of implant use


  • Assess children at 3 months, 6 months, 1 year and annually thereafter.
  • Combination of formal and informal assessment.
  • Checklists – LiP, CAP, SIR, IT-MAIS and MUS.S
  • Formal assessments – Pre-school Language Scales-4.
  • Access other assessments when appropriate.

Auditory Verbal Therapy

  • Not provided by NHS Scotland. Provided by some centres in England, including 2 CI Centres.
  • Available privately in Oxford and London.
  • Qualification through AG Bell Academy;
    • Cert AVT
    • Cert AV Ed
  • Qualified AV Therapists or Educators are registered on the AG Bell website.

What is AVT?

"AVT is an early intervention approach for children who are deaf and hard of hearing and their families. AVT focuses on education, guidance, advocacy, family support and the rigorous application of techniques, strategies, conditions and procedures that promote optimal acquisition of spoken language through listening."
(Estabrookes, 2006)

"A parent centred approach enabling children with hearing impairment to learn to talk through listening. It focuses on the use of audition as the primary channel for learning and gaining meaning from the environment. Parents are at the centre of this approach and take a full and active part in every session."
(Jacquline Stokes)

Principles of AVT

  1. Promote early diagnosis of hearing loss in newborns, infants, toddlers and children, followed by immediate audiologic management and Auditoy Verbal Therapy.
  2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation.
  3. Guide and coach parents to help their child use hearing as the primary sensory modality in developing spoken language without the use of sign language or emphasis on lipreading.
  4. Guide and coach parents to become the primary facilitators of their child's listening and spoken language development through active, consistent participation in individualised Auditory Verbal Therapy.
  5. Guide and coach parents to create environments that support listening for the acquisition of spoken language throughout the child's daily activities.
  6. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child's life.
  7. Guide and coach parents to use natural developmental patterns of speech, language, cognition and communication.
  8. Guide and coach parents to help their child self-monitor spoken language through listening.
  9. Administer ongoing formal and informal diagnostic assessments to develop individualised Auditory Verbal treatment plans, to monitor progress, and to evaluate the effectiveness of plans for the child and family.
  10. Promote education in regular classrooms with typically hearing peers and with appropriate support services from early childhood onwards.

Rationale for AVT

  • Aims to maximise children's spoken language through listening rather than visual cues.
    (Flexer, 2000)
  • Coaches parents to provide 'deliberately enhanced' environments for language learning.
  • Children identified through new born hearing screening and fitted with cochlear implants have access to the speech spectrum.
  • Routed in normal developmental framework – progression through a hierarchy of listening, speech, language, cognitive and communication skills.

Auditory Verbal Techniques

  • Pausing and waiting
    Give the child time to process the auditory information. Wait with anticipation for child to respond rather than repeating.
  • Modelling
    Encourage parents to model correct language models.
  • Acoustic Highlighting
    Highlight specific features of speech to make it more acoustically salient. Akin to 'motherese'.
  • Auditory Closure
    Fill in the gap with a sound, word or phrase to develop auditory comprehension and tracking skills.
  • One person speak at a time
    To avoid auditory clutter
  • Hand cue
    As a cue to listen or take a vocal turn.
  • Language expansion
    "Research has shown that children are most likely to imitate expansions over any other type of adult utterances."


  • Parent-centred approach
  • Using listening to develop spoken language skills
  • Many similar techniques
  • Using a developmental framework
  • Diagnostic therapy

Nursery Rhymes

  • Supra-segmentals – important for id and comprehension of speech and speech intelligibility.
  • Phonolgical awareness
  • Rhythm
  • Auditory memory
  • Vocabulary
  • Humour and imagination
  • Co-ordination
  • Confidence

Acoustic Highlighting and 'motherese'

  • Making a sound, word or phrase acoustically salient.
  • Particularly useful in early listening activities – reducing over time.
  • Sing-song voice.
  • Developmentally appropriate.

Early language

  • Early use of words and 'wholistic' phrases, eg; more, up, all gone, oh dear etc.
  • Speech bubble – Jacqeline Stokes – normal parent child interaction.
  • Imitation of patterns of speech.

Learning to listen to sounds

  • Targeted set of sounds using different vowels and consonants.
  • Speech that is repetitive and rich in expression and rhythm.
  • Can be used diagnostically or therapeutically.
  • NOT a particular set of sounds to be 'taught'.

Working developmentally

  • Progress through normal developmental hierarchies.
  • Important for target setting – neither too hard nor too difficult.
  • Multiple goals in each activity for each of the 5 areas.
    • Audition, Language, Communication, Speech and Cognition.

Language development table - Judy Simser

Verbs Directives, present progressive, future, past, conditional ...
Pronouns Me, my, mine, I, you, he, she, they, him, her, them, his, hers, theirs ...
Prepositions Up, down, in or on, under, behind, beside, in front ...
Negatives No, not, don't, isn't, can't didn't, wasn't ...
Conjunctions And, not the, either/or, only, everything but, neither-nor, because, so, if, before ...
Questions What's that?, What's he doing?, What's it for?, What happened?, How many?, What colour?
Auxilliary questions Do, are, is, can, does

Audition Goals - Lisa Katz

  • Detection and localisation
  • Looking from speaker to speaker
  • Preforming conditioned play audiometry
  • Respondng appropriately to meaningful sounds
  • Developing auditory memory
  • Identifying items by description
  • Following auditory closure tasks

Communication goals

  • Developing joint attention
  • Developing turn taking skills
  • Eye contact
  • Taking a vocal turn
  • Use of social courtesies
  • Conversational repair strategies
  • Topic maintenance

Development of consonants


Cognition goals - Lisa Katz

  • Development of play skills
  • Comprehension of specific games
  • Categorisation
  • Literacy related goals – rhyming, sound-letter association etc
  • Concept knowledge (bracken concepts – developmental)

Coaching parents

  • Children learn language best through interacting with their caregivers (Rhoades and Chisholm, 2000).
  • Explaining expectations and reasons WHY we are doing activities.
  • 'Online coaching' eg; language extension.
  • Developing diagnostic skills in parents by noting child's listening behaviours online or at the end of the session.
  • Have parents generate ideas about how to continue activities.

Unsing enhanced natural language environments

  • Child learns most effectively in everyday, routine environments that are meaningful and
  • Easier for parents to continue activities.
  • 'Enhanced' to provide multiple repetitions of target.s
  • Remember that language is not just taught in the 'therapy' activity – often the best language is in setting up the activity.
  • It is not the number of therapy hours or time spent at home doing therapy tasks. Nor is it the quantity or quality of the toys
  • A parent's work is a child's play!

Tell me and I will forget
Show me and I may remember
Involve me and I will understand
Author Unknown


  • Best outcomes with early diagnosis and implantation.
  • Where a child is neurologically intact, diagnosed early and aided appropriately – they
    should be talking ... quickly!
  • Aiming for age appropriate language within 1st year.
  • When input has been focused, natural and appropriate in the early stages, children don't
    require structured listening 'drills' or hierarchies at school age.
  • Huge range of factors can influence progress eg; Parent commitment, child's own abilities, additional difficulties etc.
  • Children coping within mainstream school environment.
  • Functioning well in small group situations.