Aural Rehab: Chapter 4 Auditory Stimulation In Comm

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Basic oral communication involves five key components:

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the speaker, a message (often with auditory and visual forms), a listener, feedback to the speaker, and the environment in which the communication takes place

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Both the segmental and suprasegmental components found in speech contribute to

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contribute to speech perception

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Hearing impairment results in

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results in the loss of varying degrees of segmental and suprasegmental information, which leads to problems with speech perception

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Speech has quite a bit of built-in redundancy, making it possible to

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making it possible to figure out what was said even though the listener did not perceive all the acoustical information produced by the speaker

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Auditory training is intended to

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is intended to facilitate auditory perception in the listener with impaired hearing

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Long-term auditory training therapy is not done routinely with a majority of cases with hearing loss.

However, it can be a key component of audiologic rehabilitation for

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for cochlear implant recipients, those with prelingual onset of hearing loss, and those with severe to profound impairments

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Assessment of auditory skills can provide

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can provide valuable information regarding candidacy for therapy, can help in identifying areas in need of work in therapy, and can be useful in outcomes assessment

Numerous forms of communication strategies are available to assist in making communication more successful.

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A number of models have been developed for providing AR on a short-term basis, and these usually are incorporated into

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are incorporated into the hearing aid fitting process

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Temporal Parameters of Speech.

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duration of individual speech sounds in our language covers a range from about 20 to 400 msec (Fletcher, 1953; Lehiste, 1976).

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A number of factors can significantly influence the

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can significantly influence the duration of a given phoneme, making the direct comparison of duration among phonemes difficult. However, vowels generally have a longer duration than consonants.

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Fletcher (1953) considered vowels to have average durations of between 130 and 360 msec, while the duration of consonants ranges from

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ranges from 20 to 150 msec. In spite of variations in absolute durational properties, individual phoneme duration does contribute toward speech perception

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Minifie (1973) pointed out that the duration of stop consonants (examples: /p/ and /b/) varies systematically in

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varies systematically in a vowel-consonant-vowel context, with correct perception of the speech sound depending, to a degree, on the durational property of the phoneme produced

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Speech Perception and Comprehension

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Our discussion has emphasized the segmental and suprasegmental aspects that constitute speech.

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Auditory Stimulation in communication

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The organization and production of these crucial elements into a meaningful oral message by the speaker and the accurate reception of this dynamic signal by the listener represent a highly complex, sophisticated process.

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mere reception of the segmented and suprasegmental elements of speech by a listener does not ensure

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does not ensure proper perception of the message

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Perception of speech implies

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implies understanding and comprehension, and the reception of speech by the auditory mechanism is only a first step in its perception.

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In its most basic form, the perception of speech may be thought of as involving a number of important components.

Among these are the following:

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Among these are the following: Detection. This basic aspect of auditory perception simply involves being aware of sound.
 
Our ability to detect speech is influenced by our hearing acuity and the intensity level of the speech signal.

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Discrimination

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refers to the ability to distinguish among the individual speech stimuli (phonemes, syllables, etc.) of our language.

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Identification

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ability to identify or label what one has heard by pointing to, or naming.

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Attention

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A fundamental ingredient in the perception of speech relates to attending to or focusing on the speaker and the message being conveyed.
 
The degree and quality of the listener’s attention will influence how well speech is perceived.

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Memory

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A key component in speech perception is the ability to retain or store verbal information for relatively brief periods or, in some instances, extended lengths of time.

is also fundamental to other components of speech perception and enables us to combine individual speech units for the purpose of deriving meaning from an entire verbal message, rather than from each individual unit of the message.

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Closure

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The perceived speech elements must be brought together into a meaningful whole. This process, termed closure, helps a person to recognize speech even when some cues are absent, as with hearing loss.

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Comprehension

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Full perception and understanding of the meaning of an auditory message.
 
Our task in audiologic rehabilitation should be to take into consideration what is currently known concerning speech perception as we address the needs of individuals with hearing impairments.

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Speech Perception and Hearing Loss

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Our success in processing speech is closely related to a number of important factors, and some of these will be discussed in the next section.

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Physical Properties.

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Information concerning the physical properties of speech is most relevant when considering the relationship between the perception of speech and hearing loss, because the degree of our success in processing speech appears closely related to our ability to receive the coded acoustical information that makes up the signal.

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The normal ear is well equipped to receive and process speech in most situations. Since most speech is normally presented at average intensity levels of around
45 dB HL, it is well within the sensitivity range of the normal human ear.
 
Also, although we are capable of hearing auditory signals ranging in frequency from about 20 to 20,000 Hz, only a portion of the entire range is

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is required for the reception of speech, since speech contains energy from roughly 50 to 10,000 Hz

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Consequently, in most listening conditions, those with normal hearing will experience

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will experience little, if any, difficulty in adequately hearing the speech sounds found in oral communication.
 
The same does not hold true for persons with hearing loss. No longer are the intensity and frequency ranges of the impaired ear always sufficient to provide total perception of the speech signal.

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One or both of these stimulus parameters may be limited such that it becomes

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it becomes difficult to hear specific speech sounds adequately for identification purposes. For example, a person with 50 dB thresholds from 2000 to 8000 Hz would have considerable difficulty perceiving the phonemes with spectral compositions that primarily involve those higher frequencies

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The Auditory Training Process

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Traditionally, auditory training has been considered a major component of the audiologic rehabilitation process.
 
Thus, its potential in assisting those with hearing loss has been expressed in major textbooks within the field of audiology, both in the past Definition and Application of Auditory Early Efforts in Auditory Training

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Definition and Application of Auditory Training

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Numerous attempts have been made to define auditory training in the past. Although similar in some respects, these definitions vary considerably according to the orientation of the definer and special considerations associated with hearing loss, such as its degree and time of onset.

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Probably the most commonly referred to definition of auditory training is attributed to

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is attributed to Carhart (1960), who considered auditory training a process of teaching the child or adult with hearing impairment to take full advantage of available auditory clues.
 
As a result, Carhart recommended an emphasis in therapy on developing an awareness of sound, gross discrimination of nonverbal stimuli, and gross and fine discrimination of speech.

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Later, in discussing the use of auditory training with children, Erber (1982) described it as

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described it as “the creation of special communication conditions in which teachers and audiologists help hearing-impaired children acquire many of the auditory perception abilities that normally hearing children acquire naturally without their intervention.”

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When considering auditory training for adults, two general objectives are usually relevant:

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(1) learning to maximize the use of auditory and other related cues available for the perception of speech and
 
(2) adjustment and orientation to facilitate the optimum use of hearing aids and cochlear implants.

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Inherent in the various views of auditory training, as well as those of other professionals in audiologic rehabilitation, is the notion that persons with hearing impairment can be

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can be trained to maximize the use of whatever amount of hearing they possess.

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The ultimate aim of auditory training is, therefore, to achieve maximum communication potential by

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to achieve maximum communication potential by l to its fullest. In a sense, auditory training is often designed to improve one’s listening skills, which will result in improved speech perception.

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Although the primary goal of auditory training is usually to maximize receptive communication abilities, it is important to point out that achieving this basic goal can result in

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can result in other important accomplishments as well, including acquisition of more proficient speech and language skills, educational and vocational advancement, and successful psycho-social adjustment

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As indicated earlier, if the communication skills of persons with hearing impairment can be improved,

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other areas of concern, such as educational progress, will be facilitated as well.

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Carhart’s approach to auditory training for prelingually impaired children was based on his belief that

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was based on his belief that since listening skills are normally learned early in life, the child possessing a serious hearing loss at birth or soon after will not move through the normal developmental stages important in acquiring these skills

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Likewise, when a hearing loss occurs in later childhood or in adulthood, some of the person’s auditory skills may become

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may become impaired even though they were intact prior to the onset of the hearing loss

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Carhart outlined four major steps or objectives involved in auditory training for children with prelingual deafness:

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1. Development of awareness of sound
2. Development of gross discriminations
3. Development of broad discriminations among simple speech patterns
4. Development of finer discriminations for speech

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Development of an awareness of auditory stimuli and the significance of sound involves having the child acknowledge the presence of sound and its importance in his or her world.
 
The development of gross discrimination initially involves demonstrating with

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initially involves demonstrating with various noisemakers that sounds differ

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Once the child can successfully discriminate grossly different sounds, he or she is exposed to finer types of discrimination tasks that include variation in

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include variation in the frequency, intensity, and durational properties of sound.
 
When the child is able to recognize the presence of sound and can perceive gross differences with nonverbal stimuli.

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Carhart’s approach calls for the introduction of activities directed toward learning gross discrimination for speech signals.
 
The final phase consists of training the child to make

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consists of training the child to make fine discriminations of speech stimuli in connected discourse and integrating an increased vocabulary to enable him or her to follow connected speech in a more rapid and accurate fashion.
 
Carhart also felt that the use of vision by the child should be encouraged in most auditory training activities.

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Adult Procedures:

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Because adults who acquire a hearing loss later in life retain a portion of their original auditory skills, Carhart recommended that auditory training with adults focus on reeducating a skill diminished as a consequence of the hearing loss.
 
Initially, Carhart felt that it was important to establish “an attitude of critical listening” in the individual.

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Because we often communicate under less than ideal listening circumstances,
Carhart advocated that auditory training sessions for adults be conducted in three commonly encountered situations:

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(1) relatively intense background noise
(2) the presence of a competing speech signal
(3) listening on the telephone.

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This emphasis on practice in speech perception under listening conditions with decreasing amounts of redundancy has been emphasized more recently, as noted by Sweetow and Henderson-Sabes (2009).
 
According to Carhart, the use of hearing aids (and cochlear implants) is vital in

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is vital in auditory training, and he recommended that they be utilized as early as possible in the auditory training program.

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These recommendations were consistent with Carhart’s belief that systematic exposure to sound during auditory training was

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was an ideal means of allowing a person to adequately adjust to hearing aids and assist in using them as optimally as possible.

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Current Approaches to Auditory Training

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The basic intent of more recent methods of auditory training remains the same, that is, to maximize communication potential by developing to its fullest the auditory channel of the person with hearing loss.

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Candidacy for Auditory Training

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In recent times, auditory training therapy has been utilized selectively with certain types of patients, but only occasionally with most others. Its most common use is with children with prelingual sensorineural hearing loss, especially those with moderate-to-profound degrees of loss with congenital onset.

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Another targeted population for auditory training in recent times has been

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cochlear implant recipients, both children and adults. There is strong evidence that a structured program of listening training enhances the benefits derived from a cochlear implant.

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Although extensive auditory training typically has not been utilized routinely in the past with hard of hearing adults, certain factors, such as exceptionally poor speech perception and/or a severe to profound degree of loss, resulted in

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resulted in its application on a selective basis.

However, in recent times its use with hard of hearing adults on a more routine basis has been advocated by many in conjunction with facilitating the effective use of hearing aids.

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Methods of Auditory Training

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The more current approaches to auditory training vary considerably.

According to Blamey and Alcantara (1994), it is possible to categorize them into one of four general categories, based on the fundamental strategy stressed in therapy:

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Analytic:

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Attempts to break speech into smaller components (phoneme, syllable) and incorporate these separately into auditory training exercises.
 
Examples include exercises that emphasize same–different discrimination of vowel or consonant phonemes in syllables (e.g., /bi-ba/), or words (e.g., /k Ip-kIt/), or require the listener to identify a word within a closed-set response format (e.g., run–money–bat).

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Synthetic:

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Emphasizes a more global approach to speech perception, stressing the use of clues derived from the syntax and context of a spoken message to derive understanding.
 
Training synthetically involves the use of meaningful stimuli (words, phrases, sentences). This might involve practicing sentence perception based on prior information about context (e.g., having lunch, a classroom discussion on government) or having the clinician name a topic and present related words or phrases that the individual must repeat back.

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Pragmatic:

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Involves training the listener to control communication variables, such as the level of speech, the signal-to-noise ratio, and the context or complexity of the message, in order to obtain the necessary information via audition for understanding to occur.

For example, the person with hearing loss practices how to effectively use conversation repair strategies, like asking questions or requesting that a statement be repeated or clarified, to comprehend a paragraph read by the clinician.

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Eclectic:

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Includes training that combines most or all of the strategies previously described. While the auditory training programs to be described all have analytic, synthetic, or pragmatic tendencies, most would best be described as eclectic, since more than one general strategy for the training of listening skills typically is used with a given child or adult.

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Cochlear Implant Manufacturers:

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The major cochlear implant manufacturers have made available some excellent supportive programs for developing/improving auditory skills and facilitating the use of cochlear implants for both children and adults.

For example, Cochlear Corporation distributes Sound and WAY beyond, a self-paced interactive software program designed for use by adults and teens at home to practice their listening skills.

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Another program, designed for teenagers, Nucleus Hear We Go, contains numerous

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contains numerous listening activities related to a variety of topics of interest (sports, food, television, etc.).

HOPE Notes is a program designed for both cochlear implant and hearing aid users to help improve the perception and enjoyment of music.

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Listen, Learn, and Talk

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is a comprehensive program for developing listening skills and language in children from birth to school-age. Information regarding each of these programs can be obtained via www.cochlearamericas.com/Support.

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MED-EL has developed a variety of programs to facilitate listening in children and teens, including Musical Ears and TeenTrain.

MED-EL also has made available

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also has made available a training program titled AUDITRAIN, which is de-signed to help adult cochlear implant users maximize the use of their hearing through 22 individual lesson plans that contain both analytic and synthetic listening activities.

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Finally, Advanced Bionics has developed an extensive series of web-based materials for parents of recently implanted children, as well as members of the cochlear implant team. These materials cover

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These materials cover a variety of important topics, including detailed information and activities related to auditory skill development.

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Computerized Approaches to Auditory Training:

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Computerized approaches to auditory training have emerged in recent times and have shown potential for providing valuable training and information related to enhancing listening skills.

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CasperSent

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is a program involving computer-assisted speech perception testing and training at the sentence level. It consists of sixty sets of sentences involving twelve topics and three sentence types.

The sentences can be presented by lipreading only, hearing only, or a combination of the two perceptual modes and the patient attempts to repeat as much of each sentence as possible.

The sentences can be self-administered by the person with hearing loss or by a clinician, and correct/incorrect feedback is provided after each response.

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CAST,

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or computer-assisted speech training, is another auditory training program developed originally for use with cochlear implant recipients.

It includes a variety of training material, including non-speech signals like pure tones and environmental sounds, and speech signals ranging from phonemes to monosyllabic words and sentences produced by different talkers. The program is adaptive, adjusting level of difficulty based on patient performance.