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AVT – by Daniya

Once we have diagnosed a hearing loss & given hearing aids or cochlear implantation, the treatment does not end there.

There are different methods for habilitation. To name a few, there is cued speech, sign language and total communication etc and then there is auditory verbal therapy. IN the traditional methods, gestures, lip reading and tactile clues are provided. For eg. If the child has to be taught p, the lip movements are shown as --- and when the child imitates the movement, the sound is produced as "P", here lip reading is given. If the child has to be taught "S", since the production of the sound is not visible, the child is made to feel the friction of the air released while producing "S". So with these methods even, when children don't hear these sounds, they produce them though not very clear. In AVT all these methods are not used only auditory clues are used.

Earlier, traditional methods were the only option because we were unable to provide all the speech information through hearing. However today, because of technological advancements, majority of children with sensorineural hearing impairment have the potential to access all of the sounds of spoken language through listening alone. This is provided either through good quality digital hearing aids or through cochlear implants. So, if the child can hear all sounds then why not teach them speech through listening alone.

Now let's see why verbal language should occur through auditory input itself. Because hearing is one of the active agent in a child's cognitive and communication development. And if we provide visual clues, we will be minimizing the ability to listen as a normal child. For eg. If I tell a normal hearing person to try to understand my speech through lip movements alone, he sis not supposed to listen to me. So if I say 'thatha', 'poocha', 'chaya', 'amma' etc., the person comprehends my speech through auditory mode before the visual information is sensed by the brain. This happens because a normal hearing person's brain is used to understanding speech through listening alone. But if I eliminate the auditory clue and then say 'thatha', 'poocha', 'chaya', 'amma' etc., he is in a better position to understand speech through lip movements. This concept can be applied in a reverse manner in case of hearing impaired children. That is they can concentrate better on auditory information if visual clues are not provided.

And also, if we provide visual clues, tactile feedback and lip exaggerations, this leads to exaggerated speech and limited auditory skills. This in turn will create social and communication problems because they are able to follow the speech of only those known to them. Eventually it ends in such a way that they are able to cope only in a deaf environment.

So it is clear that listening is the main factor which influences the speech and language development of a child. In AVT the same developmental stages of a hearing child is followed. There are different levels starting from awareness of sounds to advanced listening skills.

Now we begin therapy with sound awareness. That is the child gives us a behavioral response that he has heard a sound. For example he will turn his head, smile or nod in response to different sounds. In the next step, the child starts associating meaning to those sounds. That is the child hears the doorbell he relates that sound to somebody waiting outside for the door to be opened. Also he starts following simple commands like sit down, come here, close your eyes etc.
Once this is achieved, we move on to imitation and expansion. In this stage the child starts to speak. He learns to repeat what he has heard and he begins his social communication.
The final stage is that of advanced listening skills. Now the child is able to listen even in the presence of background noise, understand speech from a distance, participate in group conversions, talks through telephone etc.
When a child completes all levels, he or she is ready to leave this programme.

Now let's see what the main components of AVT are. When a child first enters an auditory habilitation programme, a pre therapy assessment is made to know where to start with the therapy.
After a baseline assessment, goals are set for each child. It will include the five areas like audition, speech, language, cognition and communication. Individual session is another important aspect in AVT. Each child will be having different levels of listening skills, learning styles, interests and general speech and language levels. So it is easier to teach in an individual session.

Parental participation is also another important aspect in AVT. Parents learn auditory verbal techniques most effectively through active participation in a session rather than sitting outside the therapy room.

Now we have said so much about the benefits of AVT. Does this mean that AVT can be done in all hearing impaired population? The answer is NO. Because there will be children who are unable to procure good hearing aids or who cannot afford cochlear implants. So if the aided thresholds cannot be improved with these hearing devices, then they are not going to develop through and auditory learning programme. Also in case multiple handicapped like autism, mental retardation etc along with hearing impairment, some tactile and visual clues has to be used.

In AVT parents are taught to create environments that provide listening and spoken language through out a child's daily activities. The family is one of the most influential forces in human life. How we educate, nurture, guide and support the parents, it will have significant effect on the development of their child.

Also, AVT encourages maximum use of hearing in the overall development of a child. This we have discussed in detail already.

However it must be understood that simply providing hearing devices does not mean the sounds will automatically be perceived or interpreted. For this to happen, the child must learn to listen using these devices. That is "listening is different from hearing". Listening is actually what we do with hearing. If two people talk in Chinese of Japanese language next to us, we do no pay attention to that at all. That is, though the sounds enter our ears, our brain is not consciously listening to the sounds as we are not able to associate meanings to these sounds.

This means that the child has to learn to detect and interpret the sounds, through which the child's capacity for spoken language is maximized.

The concept of critical language learning period also is an important factor in this aspect. The importance of learning speech during this critical period is already discussed. Speech and language skills do not emerge spontaneously for a hearing impaired child after this period just because hearing is provided. Therefore concentrated habilitation is required.

Otology Master Class
From the Organizing desk

Dear friends,

MESIARC CME is here again. We have always strived to bring you the best in Otology, over the past 10 years, Our live surgery workshops, have focused on cutting edge surgery, detailed teaching, scientific deliberations of the highest order and top class video coverage from one of the most advanced otological theatre suites in the world this time, we are focusing on the enigma of budding otologists - cholesteatoma and Otosclerosis. Two very diverse conditions, but requiring surgical expertise of the highest order to deliver good results. The two-day surgical workshops will feature both myself and a luminary in Otology, Dr. Ashesh Bhumker from Thane, Mumbai and we would be demonstrating in detail the finer aspects of surgical techniques that can be adapted by a keen otologist to sustain good results over time.

We have lined up an array of diverse cases- and the techniques that we intend to demonstrate include minimal access stapedotomy, Laser stapes surgery, stapes surgery with stapes head amputation for tendon preservation, bone obliteration technique for cholesteatoma, a variety of grafting techniques, intact canal wall tympanoplasty for limited cholesteatoma and a series of revision surgeries.

Do send in your registrations early as we have to limit attendance to 70 seats. A smaller crowd is ideal for active discussions which is something so characteristic of MESIARC CME programs and we do not want to deviate from that agenda.

Yours truly,

Manoj MP  
Organizing chairman

Otology in Perspective Live Surgery 2015
From the Organizing desk

Mesiarc brings you a unique live surgical workshop- a demonstration of both endoscopic and microscopic otologic skills.

Otologic surgery is special for its intricate anatomy, extreme precision and attention to detail. Traditionally done with the operating microscope, and now in some centers across the world with the endoscope, the repetoire of the art is widening.

Confusion persists. Advocates of endoscopic work claim that the microscope is passe, and traditional surgeons laugh off the ability of the one handed

The truth lies somewhere in between; there are specific conditions that require either of both of the techniques. Dogmatism, they say, is the end of science.

Mesiarc brings you a unique live surgical workshop- a demonstration of both endoscopic and microscopic otologic skills.

MESIARC has always stood for dissipation of knowledge and the live surgical workshops are not pubilicity events, nor are they grandiose. We have just one agenda- to educate.

This workshop with a difference aims to demonstrate both endoscopic and microsopic skills in otologic surgery, while attempting to define which is more suitable for what. Do come and enjoy!

Yours truly,

Manoj MP  
Organizing chairman

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