Book excerpt – James Jerger: A Life in Audiology

The following excerpt is from the autobiography, James Jerger: A Life in Audiology

American Academy of Audiology

The AAA is now in its 28th year. Younger members may not appreciate what it has meant to our profession. Before the Academy was launched in 1988 we were the step-children of the American Speech-Language-Hearing Association, commonly abbreviated as ASHA. We followed their code of ethics, accepted their certification programs, attended their conventions, and published in their journals. How this came about was essentially an accident of history. Most of the earliest audiologists were people originally trained in speech science and speech pathology. As such, ASHA was their natural home and they were comfortable within its ranks. Raymond Carhart’s doctoral dissertation, for example, concerned a model of the human larynx.  But as younger people became audiologists they did not share the common bond with speech science and speech pathology so typical of their mentors. As the field of audiology grew, some of the younger members began to ask whether we might not be better served by creating our own national professional organization. Expressing this view, however, met with stern disapproval. Our elders insisted that fragmentation must never happen, that we must always remain one profession because you could not separate hearing from speech and language; they were all part of the unique process we call “human communication.”  I always thought this argument specious. For example, you cannot separate the brain from the foot: they are both part of the whole body, but there are quite distinct medical specialties to treat their disorders. Certainly the more you know about language and speech the better, but that doesn’t mandate that you belong to their professional organization.

In any event, opponents of fragmentation failed to appreciate that ASHA itself began as the American Academy of Speech Correction (AASC) by fragmenting off from the National Association of Teachers of Speech (NATS) in 1925. NATS in turn was formed by splitting off from the National Council of Teachers of English (NCTE) in 1914.

In 1958 I was elected to ASHA’s executive board. At one of our meetings, I suggested that we consider setting up special interest groups that would lend some separate identity to various clearly distinguishable groups within the organization. There was much shoe shuffling, and some support from the aphasia people, but little general willingness to pursue the topic. A fellow board member, one of the revered elder statesman in audiology, came over to me as the meeting broke up, put his hand on my shoulder, and said, “Jim, it will never happen. They are afraid we will split off.”  Actually the idea of special interest groups within ASHA did eventually happen, but only after we had formed AAA.

Nothing much transpired for the next few decades, but matters came to a head at the 1987 ASHA convention in New Orleans. Rick Talbot had organized a session on “future trends in audiology.” There were five of us on the panel: Jay Hall, George Osborne, Charles Berlin, Lucille Beck and me. Each presented a thoughtful glimpse at what the future might hold in their particular area. I was the last speaker and my message was simple. I said, “I think it is time for audiologists to form their own professional organization” The response from the audience shocked me. There was a deafening roar of approval, which I truly had not expected. I think that everyone on that stage was also amazed.

Back in Houston I asked colleague Brad Stach what he thought of the idea. He was leery at first, but came around when I drew an analogy with an umbrella organization like the American Medical Association, under which each medical specialty had its own organization, its own publication and its own convention. In retrospect the analogy is not quite apt, but it convinced Brad to take up the cause. We put together a list of 35 audiologists that we considered leaders in their respective areas and sent each one a letter of invitation to come to Houston for a two-day meeting to discuss the possibility of forming a new organization “of, by, and for” audiologists. Only one invitee declined. The rest arrived, at his/her own expense, ready to consider the idea.

We met in the ballroom of a hotel just across Fannin street from the Methodist Hospital. The first morning was chaotic. It was difficult to believe that the group could ever agree on anything. By the end of the second day, however, there was general consensus that the effort at least ought to be attempted. In 2009 I wrote, in my book Audiology in the USA, the following:

 “The first year of the Academy’s existence, 1988, was an uncertain time. The founders were not at all sure that their efforts would succeed. They knew what they wanted to do, and where they wanted to go, but recognized, with some trepidation, the formidable forces arrayed against them. The primary concern was, of course, the ASHA.  It already counted, at that time, more than 8000 audiologists among its roughly 60,000 members, and was not disposed to view this defection in a collegial manner.”

If I were to rewrite that last sentence today, I would undoubtedly use more colorful language, so I had better not try. That passage does illustrate, however, what I perceived to be the most important reason to break away from ASHA. Speech pathologists outnumbered audiologists in the ratio of about 8:1. But, profession-wise, speech pathology is, and perhaps always will be, based on an educational model, whereas audiology is based on more of a medical model. At that time the bulk of speech pathologists worked as therapists in the public schools of America. They worked primarily with children. Most held only the bachelor’s degree.  Our profession, on the other hand, is more like a medical model. Most of us are engaged in clinical services, either in private practice, or in medical environments. At the time we started the Academy, most audiologists held the master’s degree, and there was already pressure to upgrade to the doctoral level, which we have since accomplished with the AuD degree (a move, incidentally, with which ASHA did not initially share our enthusiasm.) Many of us felt that we would never be able to achieve the much-desired doctoral level degree until we were free of dominance by ASHA.

Love, Talk, Read: Early Intervention Strategies for Infants and Toddlers At Risk for Language Impairment

Celeste_Roseberry-McKibbinRoseberry-McKibbin_ILSSLIB_2e

By Celeste Roseberry-McKibbin
Author of Increasing Language Skills of Students From Low-Income Backgrounds: Practical Strategies for Professionals, Second Edition
and co-author of the forthcoming Comprehensive Intervention for Children with Developmental Delays and Disorders Practical Strategies (10 book set)

Statistics have documented the precipitous rise of children diagnosed with Autism Spectrum Disorder (ASD), language impairment, and other atypical developmental profiles. For example, according to the Centers for Disease Control and Prevention (2016), 1 in 68 children today is diagnosed with ASD. Many times, these children do not receive intervention until they are 4 years old or even older. Recent research has documented very exciting outcomes that can occur when these at-risk children receive early intervention, which can start as early as 6 months of age. Speech-language pathologists can help caregivers begin, very early in their children’s lives, to implement strategies that improve their language outcomes. The strategies can be summed up in three words:  love, talk, read. Let’s start with love.

Love

Relationships are the cradle of all learning. Babies and young children above all must feel attached to their caregivers through love, attention, and bonding. It is critical, in the early weeks and months of life, for caregivers to respond immediately and with love when a baby cries. Immediate responses help infants to bond with caregivers and trust their world. Leaving babies to “cry it out” teaches them that the world is not a safe place, and can create a shaky foundation upon which to build later language interaction. Thus, immediate responsiveness to a baby’s cries is a foundational building block of later language.

Talk

We have all heard the oft-repeated advice, “Talk to your baby.” This is true, and talking to babies and young children is crucial to their developing language. However, research has shown that it is actually parent responsiveness to the baby’s initiations that is even more predictive of early language development (Center on the Developing Child at Harvard University, 2016; Ozonoff et al., 2009; Tamis-LeMonda et al., 2001). When a baby looks at something, for example, the parent can follow his “line of regard” and establish joint attention, where the parent and baby are focusing on the same thing. So when the dog walks into the room and the baby’s eyes land on the dog, the parent can say, “Oh, you see Angel. (pointing to dog) That’s right, Angel just came in.” When the baby points, the parent can look at what the baby is pointing to and comment—“Oh, you are pointing at the red balloon. The balloon is pretty!” When babies make sounds, the parents can respond with immediate imitation and add new sounds as well.

Ozonoff et al. (2009) conducted a study with parents of infants (6–15 months of age) suspected of having ASD. Parents were coached to create pleasurable social routines to increase their children’s opportunities for interaction. Parents used toys and words to attract their babies’ attention, and also imitated their babies’ sounds and intentional actions. The treatment consisted of 12 one-hour sessions with the infant and parent, followed by a six-week maintenance period with biweekly visits and follow-up assessments at 24 and 36 months of age. The study’s results showed that in contrast to a control group whose parents did not receive coaching, the children who received the intervention had significantly more ASD symptoms at 9 months of age, but significantly lower autism severity scores at 18 and 36 months of age. By age 3, the group that received the intervention had neither ASD nor developmental delay.

When the baby begins to say words at around 12 months of age, parents can extend their utterances. Extensions have proven to be some of the most powerful ways to increase children’s language skills.  So, for example, if the child points to the dog and says “doggy!” the parent can say, “Yes, our doggy Angel just came into the room and she is wagging her tail.” If the child says “more juice,” the parent can say, “You are thirsty, and more juice is available. Here you go!” When parents add words and new meaning to children’s utterances, semantic and syntactic skills grow. The best part is that this can be done in any language, even if the caregiver is nonliterate and has little extra time. Extensions can easily be added to families’ daily routines with no extra expenditure of time or money.

Read

Parents can share books even with babies, reading and pointing out pictures. Simple books with colorful pictures are ideal. If parents do not read, they can talk about pictures on the pages. Parents can label pictures and actions in the pictures, saying things like, “Look—there is Thomas the Tank Engine! (pointing to Thomas). Why is he happy? (pause) Oh, he is happy because Percy the Train just came up to him and wants to play.” Babies and some young children will not answer questions, but parents can ask the questions, pause for a few seconds, and then answer the question themselves. This shows the developing child that, eventually, turn-taking is expected. Routines such as this help establish joint attention, reciprocity, and eventually conversational turn-taking. Daily sharing of books with babies and young children establishes pre-literacy skills, which are critical building blocks for later literacy.

Summary

For infants and young children who are at risk for language impairment and other developmental issues, caregivers can focus on three simple strategies: love, talk, read. Research shows that early intervention, beginning in infancy, can have exciting and dramatic results in terms of helping children achieve successful language and life outcomes.

For more information, visit http://lovetalkread.com.

 

References

Center on the Developing Child at Harvard University. (2016). Serve and return. Available at http://developingchild.harvard.edu/science/key-concepts/serve-and-return/

Centers for Disease Control and Prevention. (2016). Autism spectrum disorder. Available from https://www.cdc.gov/features/new-autism-data/index.html

Ozonoff, S. et al. (2009). How early do parent concerns predict later autism diagnosis? Journal of Developmental and Behavioral Pediatrics, 30(5), 367–375.

Roseberry-McKibbin, C. (2013). Increasing language skills of students from low-income backgrounds: Practical strategies for professionals (2nd  ed). San Diego, CA: Plural Publishing, Inc.

Tamis-LeMonda, C. S., Bornstein, M. H., & Baumwell, L. (2001). Maternal responsiveness and children’s achievement of language milestones. Child Development, 72(3), 748–767.

For Aspiring Singers, Ignorance Is Never Bliss!

Jan_Bickel Bickel_VT2E

By Jan E. Bickel, DMA, author of Vocal Technique: A Physiologic Approach, Second Edition

Singers must understand how to maintain their vocal and overall health in order to keep vocal production at the high levels required of them. In order to achieve this understanding, singers need in-depth knowledge of the anatomic and physiologic function of the complete vocal instrument, a pedagogically well-trained voice teacher, and the knowledge that they can reach out to a team of voice professionals (voice teacher, otolaryngologist, speech-language pathologist, and possibly others) who understand vocal technique and pedagogy as well as voice science and medicine. It is particularly important for aspiring singers to know they have a professional team ready and appropriately trained to help when vocal difficulties arise. The aspiring singer’s trust in this team of professionals must be established at the earliest levels of vocal training. If an aspiring singer is afraid to seek help from the voice teacher, otolaryngologist, and/or speech-language pathologist, valuable time will be lost in vocal development, damage to the vocal instrument may occur, and the aspiring singer may decide to choose another career path. It is imperative that speech-language pathologists and otolaryngologists have some training in vocal pedagogy if they wish to accept singers or aspiring singers as clients, and that voice teachers have a functional understanding of voice medicine and voice science. Ignorance is the quickest path to voice disorders for the aspiring singer.

I wrote Vocal Technique – A Physiologic Approach with the intention of appropriately educating and providing a strong foundation for aspiring undergraduate singers, whether their desire was to enjoy singing as amateurs, or perform as professional singers. In my teaching of undergraduate students, I found these young singers frequently able to produce very beautiful vocal sounds, but having little or no knowledge regarding how their vocal instrument functions when speaking and singing. Most of these singers seemed to have no idea what to do or whom to turn to when their voices were not functioning well. In addition to having a clear concept and understanding of the anatomy and physiology of the vocal instrument, they need to understand how to maintain that instrument on a daily basis; i.e. vocal hygiene, breath management, vocal exercises, careful attention to speaking voice production, and determining what might be detrimental to maintaining healthy vocal folds and bodies. I use Vocal Technique – A Physiologic Approach to teach undergraduate voice classes, initial voice lessons, and again in the vocal pedagogy course in the senior year. I find that students who fully understand the information presented within the book progress much more quickly in the voice studio, and I rarely find them in vocal distress.

Excellent singing requires appropriate posture, refined breath management skills, efficient phonation and resonation techniques as well as the ability to articulate in multiple languages without disturbing the vocal production. Professional classical singing requires perfect phonation; i.e. a clear and resonant tone quality, the ability to create a variety of tone colors, excellent dynamic control, accurate pitch, and the ability to infuse the vocal tone with many appropriate emotions. This means the aspiring singer must have the discipline and dedication to become a vocal athlete with the creativity and imagination of the best professional actor. Learning to sing well enough to perform for the public requires much more than the average person can even imagine. Singers cannot afford to be ignorant about any aspect of their profession if they are to be successful.

There are issues beyond vocal technique that can cause a very well-trained singer to have difficulty with his or her voice – respiratory infection, acid reflux, allergies, inability to “support” the voice appropriately because of bodily injury or illness, interruption in sleep pattern, stress, aging, dehydration, fatigue, and many more. A singer must know intimately his or her voice and how it functions when healthy so that when it is not functioning normally, he/she is fully aware and comfortable reaching out for support from the appropriate professional. A voice teacher can be of great assistance in many cases, but sometimes a singer needs to see a laryngologist, a speech-language pathologist, or a vocal specialist for proper diagnosis and treatment. The demands of professional singing necessitate excellent health, physical conditioning, and careful use of the speaking voice as well as the singing voice, so the aspiring singer must learn how to maintain his or her instrument early in the learning process.

I posed the following question, among others, to 35 undergraduate and amateur singers participating in a choral ensemble and/or a freshman level voice class: “Do you think singers, in general, are reluctant to see an otolaryngologist (ENT) or a speech-language pathologist (SLP) for problems with their voices? 16 responded “yes,” 18 responded “no,” and one did not answer. Of the 16 who responded that singers are indeed reluctant, three had actually seen an ENT or an SLP for a vocal issue. One singer who said she had not seen an ENT or SLP wrote about having “muscle tension dysphonia,” which would seem to indicate that she actually had seen an ENT or an SLP for diagnosis, but did not want to acknowledge this visit. Another respondent wrote that he had “strain and discomfort when singing,” but had never seen an ENT or SLP. Of the respondents who answered that singers are not reluctant to see an ENT or SLP, only two had seen an ENT or SLP, while eight of the respondents made the following statements regarding their own vocal health: “trouble with speaking voice,” “lost voice completely,” “voice hurts when I sing,” “belting created vocal problems,” “laryngitis due to asthma, allergies and bronchitis,” and “unresolved tinnitus, causing problems with pitch matching.”  It follows that these singers might have been helped by a laryngologist or speech-language pathologist, but chose not to reach out to make an appointment.

When asked why an aspiring singer might be reluctant to see an ENT or SLP, the respondents made the following statements: “Singers think the problem is fixable by themselves,” “Fear of being told that there is irreversible vocal damage,” “It can be seen as embarrassing or you don’t want to admit you have a problem,” “Some singers simply resign themselves to discomfort or stop singing altogether,” “Singers feel they can resolve issues themselves by rest and homeopathic methods,” “They don’t want to admit there’s a problem because of the competitive nature of auditions. . . ,” “Perception is the ENT does not care about solving vocal problems for amateur singers,” “It is hard for a singer to admit there is something wrong with their vocal mechanism,” “Singers assume a referral means the voice is bad/sounds bad.”

When asked the same question, two professional singer/voice teachers responded with these comments: “I feel strongly that singers, myself included, are afraid to hear that something may be wrong. I also think that singing is a very expensive endeavor, and the thought of having to spend more money on doctor visits, or treatments, in addition to the cost of taking lessons, and coachings and paying tuition, or fees for applications and auditions, is daunting,”  “The ENT I saw did not at all quell my fears. He told me that I had polyps (which I later found out was not the case) and suggested that I start coming in once or twice a week to help rebuild my voice. I had such an uneasy, unpleasant feeling about it that I went maybe twice. He did some pathetic vocal warm-ups that didn’t teach me anything and sent me to work with an SLP down the hall. Likewise, those exercises felt silly and I never felt reassured that this was going to make me better in any way.” This singer later went to a laryngologist and an SLP, both specifically trained to work with singers, and the results were entirely different as stated: “He was very kind, performing a gentle procedure to examine my vocal cords. He printed out photos and explained very thoroughly what I was looking at . . . the SLP was very kind as well. Her exercises were thoughtful, helpful and specific. She gave me reasoning behind every one of them. I actually followed through and did them every morning.” This singer went on to complete a Master of Music degree in vocal performance and to sing several opera roles successfully and is now a professional actress. Clearly, appropriate preparation of the otolaryngologist and speech-language pathologist in working with singers is important. There is no place for ignorance in the area of vocal technique and pedagogy for these professionals if they wish to take on singers as clients/patients.

Aspiring singers spend much one on one time with their voice teachers, perfecting their technique, and learning to trust the voice teacher implicitly. This trust is built up over time, and is an essential part of the training of the singer. “Singing teachers are not only music educators, they are also guardians of their students’ voices. An astute teacher does not just help prevent vocal difficulties by providing a student with expert, healthy singing technique; he/she also is often the first person to detect a vocal problem and is usually regarded by the student as the source of all knowledge about anything vocal.” (Heman-Ackah et al., 2008)

 When a vocal issue arises, the voice teacher is usually the first to hear it in the singer’s voice, and the singer naturally trusts the voice teacher to “fix” the problem. When the teacher is unable to help the singer resolve the issue, the student begins to feel uncomfortable, worried, and even desperate. Their thinking follows the path – if my voice teacher can’t “fix” the problem, it can’t be fixed. I find that undergraduate student singers are particularly fearful of a referral to the laryngologist, even when I explain that this doctor is trained to diagnose and help resolve the vocal difficulty, not to criticize or place blame. I find that many singers find the idea of getting “scoped” to be quite frightening, even though I introduce this procedure in the freshman voice class, showing a video of a singer in the process. I want them to understand this is not painful and will help to diagnose the problem. Perhaps more importantly, for the aspiring undergraduate singer there is a clear social stigma attached to visiting a laryngologist, so if the singer does make an appointment, he or she will keep it a secret.

When the laryngologist refers a singer to an SLP, this seems to be even more difficult for the singer to accept. It says to the singer that it is his or her own fault that he/she has a vocal problem. If the SLP is not knowledgeable regarding vocal technique, and works with the singer as if he/she is the same as every other client who comes into the office for voice therapy, I will have a very difficult time convincing my student singer to continue with appointments as advised by the laryngologist. An SLP working with singers MUST have some training in vocal technique and vocal pedagogy and should be willing to work in ways that are familiar to the singer from voice studio work.

If there is a diagnosis of vocal nodules, even though the voice teacher may have suggested this might be the case, it is always a shock to the singer. The singer generally comes back to the studio depressed and feeling as though his or her singing life is over. Frequently, vocal nodules can be removed through careful vocalizing and establishment of healthy speaking and singing technique, but aspiring singers want an instant cure. Many will choose to do surgery, even when the laryngologist says it is not really necessary, so they can put this diagnosis in the past as quickly as possible. The singer does not want to consider the need to do preoperative speech therapy, surgery followed by vocal rest, postoperative speech therapy, and, finally, slowly bringing the voice back to the ability to sing with excellent technique. If the singer continues to speak incorrectly or without support the outcome, even after surgery, will not be good.

So, what I am proposing here is that voice teachers give their aspiring singers an excellent foundation in vocal technique – posture, breath management, phonation, resonation, etc., and carefully teach them about the anatomy and physiology of speaking and singing so they understand the importance of establishing an appropriate speaking pitch, not screaming at the college football game, not speaking over noise at the local club, singing music from the correct voice category, and so many other directives coming from the teacher. Voice teachers should insist that their students see videos such as the ones for which links are provided on the companion website for Vocal Technique – A Physiologic Approach, demonstrating the anatomic function of the larynx, lungs, diaphragm, and surrounding muscles. There are many YouTube videos demonstrating the use of the laryngoscope so that singers will know exactly what to expect when they visit the laryngologist’s office. In addition, voice teachers must coordinate with speech-language pathologists in their universities.

Speech-language pathologists need to understand and be able to demonstrate the diaphragmatic-costal breathing that a singer would use when projecting his/her voice in an opera house without a microphone. SLPs wishing to work with singers don’t need to be professional singers, but they must have a strong understanding of what is required for a singer to produce vocal tones worthy of the concert and opera stage, and it would help greatly for them to have formal training in vocal technique and pedagogy. I think this will change the way they interact with singers, and will certainly help gain the respect of their singer/clients. This should help to improve the communication between the two, and will keep the singer coming back to complete the therapy as prescribed. It will be important for SLPs working with singers to be able to use non-traditional forms of voice therapy that have a solid basis in anatomy and physiology. In order for speech therapy to be successful, the singer must be fully invested in the process, and the process must produce results quickly so the singer can get back to singing within a short period of time.  Because singers have developed higher than normal levels of vocal stamina, and phonation skills, they expect to be treated differently as a client of an SLP. If they are not, they will not comply with prescribed treatment and probably will not complete therapy sessions or exercises at home.

It is equally important for the otolaryngologist to understand vocal technique and pedagogy when accepting a singer as a patient. If the otolaryngologist understands the hesitation and fear that is present when a singer makes an appointment to see him or her, this will help the singer remain calm and accept the diagnostic procedure and the diagnosis and prescribed treatment suggestions. “As vocal athletes, singers require special diagnostic and treatment consideration when voice difficulty develops because they must maintain higher-than-normal levels of phonatory agility, strength, and stamina to repeatedly execute complex laryngeal maneuvers” (Zeitels et al., 2002). It seems best that it is a laryngologist, specialized in the care of disorders of the voice and larynx, who treats a singer, but this is not always possible. When it is not possible, the otolaryngologist must take extra care to understand how the singer thinks and uses the voice.

In addition, there must be open and complete communication among the voice teacher, the speech-language pathologist, the laryngologist, and the singer in distress at all times. As the singer generally has full confidence in his or her voice teacher, but perhaps not as much in the SLP and/or laryngologist, this communication will help the voice teacher to motivate the singer to do the appropriate exercises. If the speech-language pathologist has a good understanding of vocal technique and the mindset of the aspiring singer, this will open the door to communication and success. In this regard, two of the professional singer/voice teacher respondents to my questionnaire stated:

“I have raised concerns about my inability to speak or sing, or concerns about how     medicine will affect my singing voice. I understand that I don’t have a medical degree,   but I do know that my voice is largely responsible for my income, and my emotional       health. Concerns raised by patients should be addressed professionally and respectfully,”

Medical professionals and SLPs should “make sure you know how emotionally      connected we are to our voices. Singing is our life, an echo of our very soul. For our       singing voice to be in turmoil is as scary as telling a runner that they ruptured their          Achilles’ tendon. It’s a very big deal.”

Let’s make sure we all do our part in fully educating aspiring singers to the best of our abilities. Every singer needs to be as educated as possible about the anatomic and physiologic function of the vocal instrument in addition to the many other areas of study. Understanding these concepts fully will allow every singer to seek out an outstanding voice teacher, and will certainly help to remove fear and anxiety about reaching out to the laryngologist, speech-language pathologist, or a voice specialist when vocal problems arise. If the voice teacher, laryngologist, speech-language pathologist, and other voice professionals understand voice science, medicine, technique, and pedagogy to an appropriate extent, and communicate clearly with one another when working with a singer in vocal distress, the outcome will surely be a good one. If we communicate well with one another on a regular basis, we cannot help but replace ignorance with knowledge for our singers, clients, patients, and ourselves.

References:

Heman-Ackah, Y. D., Sataloff, R. T., Hawkshaw, M. J., Corln, V. D. (2008). Finding a voice doctor and voice care team. Journal of Singing, 64 (5), 583–592.

Zeitels, S. M., Hillman, R. E., Desloge, R., Mauri, M., & Doyle, P. (2002). Phonomicrosurgery in singers and performing artists: Treatment outcomes, management theories and future directions. Annals of Otology, Rhinology and Laryngology Supplement, 111(12), 21–40.

 

 

 

When a Client’s Behaviors Interfere with Delivery of Effective Treatment: Evidence-Based Behavioral Approaches

Christine_MaulMaul_BPCD

By Christine A. Maul, PhD, CCC-SLP, co-author of Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment

A 3-year-old child badly in need of one-on-one language stimulation clings to his mother and cries inconsolably whenever she tries to leave the clinic room. An adult being seen for elective accent reduction therapy asks numerous questions that increasingly consume valuable therapeutic time. An elementary school-aged child being treated for a fluency disorder with a token economy system coupled with response cost reacts with torrents of tears whenever a token is taken from her. All of these are cases of behaviors that interfere with the effective delivery of therapy, taken from real-life clinical situations. In all of them, the behaviors were reduced through behavioral techniques: for the 3-year-old, a modified version of extinction was applied; for the adult, questions were reduced using differential reinforcement of low rates of responding; and for the elementary school-aged child, a modification was made of response cost, which is often coupled with conditioned generalized reinforcement, such as a token economy.

Extinction. After consulting with the mother of the 3-year-old child with delayed language, it was decided that a modified version of the process of extinction should be utilized to decrease the child’s crying behavior. Extinction removes the reinforcing contingencies for a person’s undesirable behavior. Ideally, a clinician should work with a board certified behavior analyst (BCBA) to identify the exact reinforcing contingencies for a targeted behavior. In this clinical case, however, the clinician, in consultation with the mother, determined that the mother’s continued presence and the attention she gave the child in the clinic room was probably reinforcing the child’s crying behavior.
Therefore, for the next clinic session, the clinician arrived with a bagful of toys and books she hoped would be appealing to the child. The mother agreed to take the child into the clinic room and then leave. The expected tantrum behavior occurred. The clinician positioned herself in front of the door, blocking the child’s “escape” path, with her back to the child and began pulling out toys, one by one. The clinician played with each toy, remarking about how much fun she was having, but keeping her back turned toward the child. She engaged with each toy for only a brief amount of time, and, if there was no reaction from the child, she would exchange the toy she was playing with for another item. She did this with several items, none of which seemed to interest the crying child. Then she pulled out a pop-up book that made a “ding-dong” doorbell sound every time she turned the page and began reading it. The child continued to cry, but every time he heard the doorbell sound, he cried less and less, and began to approach the clinician. The sobs subsided more and more as he peeked around her back to look at the book. Finally, to the delight of the clinician and the mother observing through a one-way mirror, the child crawled into the lap of the clinician who gently started evoking one-word productions from the child through her storybook reading. The whole process took no more than 10 minutes, from the time the clinician turned her back to the time the child approached her, and the child went willingly into the clinic room for all subsequent sessions.

There are important things to remember if a clinician wants to try extinction, or this modified version of extinction. First, the process must be thoroughly explained to the parent, and the parent must be in agreement with the procedure. Second, the first time extinction is applied, an “extinction burst” is likely to occur, when the undesirable behavior escalates to even greater heights. When this happens, the procedure of extinction should continue to be applied; if not, all the client will have learned is how much of the undesirable behavior must be displayed before reinforcement is given. Third, extinction should never be used for physically aggressive or self-injurious behaviors.

Differential reinforcement of low rates of responding. In the case of the adult being seen for foreign accent reduction, the clinician suspected that the excessive question-asking behavior was probably negatively reinforced by providing escape from therapeutic tasks. Sometimes, maybe even often, clients find therapy to be aversive, and if a behavior puts off the hard work involved in therapy sessions, it is likely to increase.

The clinician decided that the rate of question-asking was so high, the most that could be done at first would be to employ a technique designed to reduce, but not entirely eliminate, the question-asking behavior. In differential reinforcement of low rates of responding (DRL), the client is warmly reinforced for performing an undesirable behavior at a lower rate. The clinician in this case explained to the client that the amount of time spent responding to her questions was seriously interfering with the effectiveness of treatment. She asked the client to limit her questions to only three per session. The clinician kept her responses to the questions very brief, and kept a tally of the number of questions asked during each session. If the client met her goal, the clinician warmly congratulated her and let her know how much her cooperation was appreciated. If the client had been a child, the clinician could have reinforced the reduced rate of undesirable behavior by offering a small prize at the end of the session; for adults, however, just warm acknowledgment of a job well done is usually enough.

Clinicians should be aware of the disadvantages of this technique. First, the technique will only serve to reduce a behavior. After the behavior has been reduced through DRL, further techniques will have to be employed to eliminate it. Second, a phenomenon known as generalized suppression of a behavior may occur. Consider the fact that asking questions is not an entirely undesirable behavior. People ask questions to seek out new information and to clarify that which is already known. If the client in the scenario provided eventually ceases to ask a reasonable number of well-considered questions altogether, generalized suppression has occurred.

Response cost and conditioned generalized reinforcement. A token economy system, such as the one employed by the clinician treating the school-aged child with a fluency disorder, is based on the behavioral principle of conditioned generalized reinforcement. People learn to work for conditioned generalized reinforcers that provide access to many other tangible reinforcers. In the natural environment, money is the most commonly sought after conditioned generalized reinforcer. In the clinic room, tokens such as poker chips, stickers, points, or happy faces can be given to a child to reinforce correct responses. The child can then exchange tokens earned at the end of the session for a prize in the clinician’s “treasure chest.”

A token economy can be even more effective when coupled with response cost, a corrective technique in which a token previously given for a correct response is taken away for an incorrect response. Children will usually work hard to keep the tokens they have earned, but sometimes, as is the case in the given scenario, a child may react emotionally when a token is taken away for an incorrect response.

Sometimes clinicians decide to simply cease administering response cost as a corrective technique when a child displays such emotional reactions. The clinician in this case, however, decided to adapt a slightly modified version of response cost. Each fluent response the child made was lavishly reinforced with three or four tokens, placed in a plastic cup. When the child exhibited a dysfluency, the clinician took one token out of the cup but did not remove it from the child’s view. Instead the clinician held the token over the cup, gave the child an expectant look, and encouraged the child to try again—“Come on, I know you can smooth it out!” Almost always, the child was able to produce the utterance fluently, and the token was plopped right back in the cup. Administering response cost in this way increased the child’s production of fluent utterances and eliminated undesired emotional reactions.

These are but a few examples of cases in which the application of techniques based on behavioral principles resulted in the reduction of undesirable behaviors that were interfering with the delivery of effective treatment. There are many other techniques that can be employed to decrease undesirable behaviors and to increase the desirable communicative behaviors SLPs seek to teach their clients. Much more detailed information regarding these and many more techniques, accompanied by protocols for session planning and recording data, are provided in Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment.

 

Talking Hearing Aids with Brian Taylor and H. Gustav Mueller

Brian_TaylorGus_Mueller TaylorMueller_2e_FDHA2E

Fitting and Dispensing Hearing Aids, a popular introductory textbook, has just been published in its second edition in September. We managed to listen in to a conversation between its two authors, Brian Taylor and H. Gustav Mueller, who were exchanging some thoughts regarding their new 2nd Edition.

BT:  You know Gus, when we wrote the first edition of this book, I remember us talking about the fact that there seemed to a fair number of professionals who maybe weren’t following Best Practice when they were fitting hearing aids.  We thought that it might simply be because they didn’t exactly know what was called for in Best Practice, or maybe it never had been laid out for them in an orderly manner.

HGM:  And we thought a book like ours might help . . .

BT:  Right.  Do you think it did?

HGM:  I’d certainly like to think so.  We sold a lot of copies, so that’s a good start!  But honestly, when I travel around, I don’t see as much change over the past five years as I thought might happen.  Let’s take pre-fitting testing for instance.  We have some great speech-in-noise tests available for clinical use like the QuickSIN, the BKB-SIN and the WIN.  We talked about all of these in the book, provided step-by-step guidelines, yet I just don’t really see an uptake—for some reason, audiologists and hearing instrument specialists seem to have a love affair with monosyllables in quiet, which really have little use for the fitting of hearing aids.

BT:  Maybe we’re expecting things to happen too fast.  I think it’s good we expanded that section on pre-fitting speech recognition testing in the current book—hopefully more readers will take notice.  And as you know Gus, I’ve always been a fan of the ANL.  I just saw that there has been over 40 articles published on that test in the past 12 years!  That’s another easy-to-do test, and it really provides information that you cannot learn by doing speech recognition testing.

HGM:  Part of Best Practice is picking the right technology for the right person.  I recall you spent a lot of time researching all the new technology that has come out in recent years for this 2nd Edition.

BT:  Things change pretty fast in that area.  I think we’ve added some great new sections on wireless connectivity, frequency lowering, and audio data transfer between hearing aids. Like the first edition, rather than getting into the intricate technical details of various features, we focus on how this technology benefits the patient. For example, in the chapter that covers wireless connectivity and audio data transfer between hearing aids, we write about how these new features enhance benefit in background noise, and how candidates are identified.

HGM:  And, of course, verification of the fitting is critical.  The best hearing aid in the world is no better than a PSAP if it’s programmed wrong.  I think our new section on speechmapping will be extremely helpful for people who are just getting started using probe-mic measures.  As we described, recent research clearly has shown that you can’t simply rely on what you see simulated on the software fitting screen.  As, of course, all those special features that you talked about, such as frequency lowering, need to be verified in the real ear too!

With all that said, however, we also know that verification alone is not enough to demonstrate to patients, their families, and even third-party payers that a new set of hearing aids is worth the investment—so, we can’t forget about outcome measures.

BT: Yes, Gus, it seems there are always a couple of new outcome measures to talk about. With all of the recent research on the impact of untreated hearing loss on other conditions, like cognitive function, social isolation, and overall mental health, we added a section on validated self-reports to measure the impact hearing aid use may have on these common conditions.  Even if you’re not inclined to measure those types of downstream outcomes, we added more detail on using the International Outcome Inventory for Hearing Aids (IOI-HA). As you know, many audiologists and hearing instrument specialists neglect to conduct any outcome measures. We cover the reasons this is a bad idea, and suggest, if you are only going to use one measure, it ought to be the IOI-HA.

HGM:  And you know, some people suggested that it was a little silly for us to use our chapter themes of country music, movies, wine tasting, baseball, and all the others, but I’m glad we kept that going in this 2nd Edition.

BT:  Me too.  Who said you can’t have fun and learn about hearing aid fitting at the same time?  After all, it’s worked all these years for the two of us!

 

Cultivating an Awareness of Generational Differences for Effective Communication

By A. Embry Burrus and Laura B. Willis
Embry_Burrus
Laura_Willis
Authors of Professional Communication in Speech Language Pathology: How to Write, Talk, and Act Like a Clinician, Third Edition

Burrus_3e_PCSLP3E

Popular literature is filled with descriptions of the term, “generational differences,” and for good reason. There are distinct differences among individuals based on when they were born, and the political, social, and economic environment in which they have grown up. This post will address the various communication styles of individuals who are currently in the workforce. Although there are differences among the generations, according to the Center for Creative Leadership, there are also similarities; namely, most people have the same basic core values: “family, integrity, achievement, love, competence, happiness, self-respect, wisdom, balance and responsibility.”

The Millennial Generation, born between 1982 and 1994 (estimate), represents a cohort distinct from their parents of the Baby Boom generation (1945–1964 [estimate]), and their predecessors, Generation X (1961–1981 [estimate]). Millennials have been generally described as optimistic, team-oriented, high-achieving rule-followers. In addition, aptitude test scores for this group have risen across all grade levels, and with the higher aptitude has come a greater pressure to succeed. It is noteworthy to mention that Millennials are the most racially and ethnically diverse generation in U.S. history. As of 2012, individuals of Hispanic origin accounted for 26.9% of the 21-and-under population (http://www.census.gov), and Asians accounted for 25.6%. Interestingly enough, this generation has been described as more accepting of diversity than past generations.

Research has shown that children of the Millennial Generation were encouraged to “befriend” their parents, as well as their parents’ friends, and as teens they became comfortable expressing their opinions to adults; therefore, they are not hesitant to challenge authority, assert themselves, or ask for preferential treatment. Studies have shown that Millennials view strong relationships with supervisors to be a crucial factor in their satisfaction with their role as supervisee, and that they expect communication with supervisors to be frequent, positive, and affirming.

In today’s society, we are taught that to be successful, we need to be self-confident. Some of the characteristics assigned to the Millennials are that they are self-assured, assertive, and perfectionistic, which, when used constructively, can be very positive attributes. It is important that Millennials are aware that to members of the older generations, this can sometimes be misconstrued as overconfidence. If a supervisor or colleague perceives you to be overconfident, this could create a number of opportunities for miscommunication and misunderstanding. You do not want to communicate to others that you have more ambition than skill, or that you already “know it all” and therefore do not need or want their input. We often advise our students to be mindful that if they are perfectionists, they should not allow this to morph into fear of failure. We remind them that it is okay to admit that they do not know something, and it is much better to do so than to seem falsely competent.

Members of Generation X, the cohort immediately preceding the Millennials, were shaped by many factors. Generation Xers learned independence, autonomy, and self-reliance early in life. They were the first to be described as “latch-key” kids, and they often took care of themselves and their siblings. They grew up in a time when divorce was commonplace, and therefore ended up in single-family or blended-family homes. As a result, they have been described as being more accepting of themselves and others, and embracing of diversity. Members of this generational cohort have been described as valuing flexibility and creativity, as well as encouraging of individualism.

According to Jean Scheid (2010), “Gen Xers aren’t afraid of technology and love new gadgets, even if it takes a little longer than a Millennial to understand how it all works. Their communication style is one brief and to the point, and e-mail is their preferred method.” Gen Xers desire feedback from supervisors and do not hesitate to offer feedback in return. On the other hand, if not kept in the loop, they may become upset and feel left out.

The “Boomers,” as they are often referred to as, make up approximately 29% of the U.S. population and 50% of the workforce. The oldest members of the Baby Boom generation are now mostly retired, and in less than 15 years, one in five Americans (the youngest members) will be over the age of 65. Those who were born at the end of this generational cohort (1960–1964), however, are still a large part of the workforce and may still embody some general characteristics used to describe this group: focused on hard work, ambitious, competitive, and believers in equality.

To summarize, it is important to always show respect by communicating clearly and demonstrating that you acknowledge what your communication partner feels is important, regardless of position or age difference. This does not mean that individuals across the generations cannot understand each other, or learn from each other; it simply means that we must take into consideration that we may have different ways of looking at the same issue. Being part of a diverse workplace may be challenging to some, yet it can provide an environment that fosters rich personal as well as professional growth.

References

Deal, J. (2015). Ten principles for working across generations [Podcast]. Center for Creative Leadership. Retrieved from http://insights.ccl.org/multimedia/podcast/10-principles-for-working-across-generations/

Schied, J. (2010). Types of communication styles: Bridging the communication gap. Bright Hub. Retrieved from http://www.brighthub.com/office/home/articles/76498.aspx

U.S. Census Bureau. (2012). Current Population Survey, 2012 Annual Social and Economic (ASEC) Supplement. Washington, DC: Author.

 

Nasal Emission Terminology Should be Evidence Based and Consistent with Physiology and Perceptual-Acoustic Characteristics

Nasal Emission Terminology Should be Evidence Based and Consistent with Physiology and Perceptual-Acoustic Characteristics (1)David J. Zajac, PhD, CCC-SLP, ASHA Fellow

Coauthor of Evaluation and Management of Cleft Lip and Palate: A Developmental Perspective

The term “cleft palate speech” has often been used to refer to hypernasality, nasal air emission, reduced oral air pressure, and compensatory articulations of speakers who exhibit velopharyngeal inadequacy (VPI). Hypernasality is defined as excessive resonance of the nasal cavity during production of vowels and voiced consonants. Nasal air emission refers to the audible escape of air during the production of high-pressure oral consonants, especially voiceless consonants. Reduced oral air pressure is the flip side of nasal air emission. When air escapes through the nose, some oral air pressure is lost. Thus, oral pressure consonantsespecially voiceless ones—may be produced with reduced oral air pressure and perceived as weak or reduced in intensity. Compensatory articulations are maladaptive gestures that are produced at the glottis or in the pharynx as a way to circumvent a faulty velopharyngeal valve. The use of glottal stops to replace oral stops is a classic example of a compensatory articulation. Hypernasality, nasal air emission, and reduced oral air pressure are passive (or obligatory) symptoms of VPI. This means that the symptoms occur as a direct consequence of incomplete velopharyngeal closure. Compensatory articulations, however, are active (or learned) behaviors and may not occur in every individual.

Although obligatory nasal air emission is a core characteristic of VPI, many confusing, overlapping, and inaccurate terms have been used to describe its perceptual manifestation. The literature is replete with terms such as audible nasal air emission, nasal turbulence, nasal rustle, and passive nasal frication. Because the velopharynx and nasal passage are complex anatomical structures— which may be significantly altered due to both congenital defects and surgical interventions associated with cleft lip and palate—the variety of terms used to describe nasal air emission should not be too surprising. Numerous other terms have been used to describe nasal air emission that is part of active (or learned) nasal fricatives and will not be discussed here. The reader is referred to Zajac (2015) for a discussion of active nasal fricatives as an articulatory error. Rather, this article will focus on terminology used to describe passive or obligatory nasal air escape.

A Brief History of Current Terminology

McWilliams, Morris, and Shelton in the first and second editions of Cleft Palate Speech (1984, 1990) described nasal air emission as occurring along a continuum. First, it could be visible but inaudible, detectable only by holding a mirror under the nostrils of a speaker to see fogging as a result of the air emission. In such a case, the nasal airflow is laminar, moving in relatively smooth fashion, and does not become turbulent, or noise producing. Clinically, visible nasal air emission typically occurs in speakers who have adequate but not complete velopharyngeal closure and normal resonance. Although visible nasal air emission should be noted when it occurs in a speaker, there are no treatment implications. Continue reading

Auditory-Verbal Therapy- Hearing, Listening, Talking, Thinking

Warren_Estabrooks

 

 

By Warren Estabrooks, M.Ed., Dip. Ed. Deaf, LSLS Cert. AVT, co-author of Auditory-Verbal Therapy: For Young Children with Hearing Loss and Their Families, and the Practitioners Who Guide Them

 

 

Globally, there is a great shift towards listening and spoken language for children who are deaf and hard of hearing.

Amazing auditory options, state-of-the-art hearing aids, and a variety of implantable hearing devices and the pursuit of excellent (re)habilitation by highly qualified practitioners working in partnerships with families, will hopefully become the standard of international health care and educational intervention for children with hearing loss around the world.

It is the work of therapists, teachers, audiologists, surgeons, social workers, and allied practitioners in health care and education to guide, navigate, and coach parents on their search for the treasure chest of spoken communication—to help them help their children discover the valued jewels of hearing, listening, and spoken conversation.  Practitioners everywhere form alliances of hope and trust with parents, and together we polish these precious gems until they sparkle and dance with life.

Why would one ever consider compromising when so much is possible?

We hope that one day we will look back and see an abundance of evidence-based outcomes, all barriers to equitable service gone, and a global focus on literacy with a deep understanding of powerful auditory access to the brain provided by state-of-the-art hearing technologies.

Renaissance man and mentor of many of today’s auditory-verbal practitioners, Dr. Daniel Ling, wrote that “auditory-verbal therapy… developed as a result of the natural outcomes of advances in knowledge, skills and technology.  As such advances occurred, new treatment strategies were devised to maximize their applications”.

Auditory-Verbal Therapy is now widely accepted because more children are acquiring, or have already acquired, the abilities to use spoken language, to interact more freely with other members of society, to obtain higher levels of academic education, and to have a more extensive range of careers, a greater security of employment and fewer limitations on the personal and social aspects of their lives” (Estabrooks, 2006).

Continue reading

AudiologyNOW! 2016 Author Signing Schedule

AudiologyNOW! attendees – Meet our authors and connect with experts in the field! Stop by the Plural booth (#301) for the following Meet the Author sessions: 


Thursday, April 14, 11:00 am – 12:00 pm
Meet Marc Fagelson, BA, MS, PhD 
Co-editor of Tinnitus: Clinical and Research Perspectives

Marc Fagelson   Tinnitus


Thursday, April 14, 3:00 – 3:30 pm
Meet Mark DeRuiter, MBA, PhD and Virginia Ramachandran, AuD, PhD
Authors of Basic Audiometry Learning Manual, Second Edition 

Mark DeRuiter   Virginia Ramachandran   Basic Audiometry Learning Manual, Second Edition


Friday, April 15, 11:00 – 11:30 am
Meet Ruth Bentler, PhD, H. Gustav Mueller, PhD, and Todd A. Ricketts, PhD
Authors of Modern Hearing Aids: Verification, Outcome Measures, and Follow-Up  

Ruth Bentler   H. Gustav Mueller   Todd A. Ricketts  Bentler_MHA.jpg

Congratulations to Ruth Bentler, 2016 recipient of the Jerger Award for Research in Audiology. 


Friday, April 15, 1:00 – 2:00 pm
Meet Anne Marie Tharpe, PhD
Co-editor of Comprehensive Handbook of Pediatric Audiology, Second Edition

Anne Marie Tharpe   Comprehensive Handbook of Pediatric Audiology

Congratulations to Anne Marie Tharpe, 2016 recipient of the Marion Downs Award for Excellence in Pediatric Audiology. 

Healing Voices

Healing Voices (1)By Leda Scearce, MM, MS, CCC-SLP author of Manual of Singing Voice Rehabilitation: A Practical Approach to Vocal Health and Wellness

Singing is a part of virtually every culture and is fundamental to our human experience. In the United States, singing is enormously popular, as evidenced by the vast number of people engaged in all kinds of singing activities. Over 30 million Americans participate in choral singing alone (Chorus America, 2009). Shows such as The Voice, America’s Got Talent, and American Idol illustrate how passionate we are about singing. From the amateur recreational singer to the elite celebrity, we sing as soloists and in ensembles, with instruments and a cappella, in classical and contemporary styles, on stage, in concert, and in the shower.

Every person’s voice is unique and identifiable, and our voices can be a big part of our identity and how we see ourselves in the world. This is especially true for singers, for whom the voice is not only intricately tied to self-image and self-esteem but also may be a source of income and livelihood, creative expression, spiritual engagement, and quality of life. For a singer, a voice injury represents a crisis. Because of the specialized needs of singers, it takes a team—including a laryngologist, speech-language pathologist, and singing voice rehabilitation specialist—to get a singer back on track following an injury or voice disorder. Singing voice rehabilitation is a hybrid profession, requiring in-depth clinical and scientific knowledge married with excellence in teaching singing.

Voice problems are rarely isolated in etiology—usually multiple factors converge to create an injury. These factors may include poor vocal hygiene, inadequate vocal technique, an imbalance in vocal load and medical problems (allergies and reflux are common in singers, but thyroid, pulmonary, neurologic, and rheumatologic conditions are among the illnesses that may affect the voice). The singing voice rehabilitation process must encompass all elements that may be contributing to the problem: medical factors, vocal hygiene, vocal coordination and conditioning, vocal pacing, and emotional factors. Continue reading