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The JISH Aural/Oral Rehabilitation Program

Children with hearing impairment need a habilitation program that will promote the development of their hearing and listening skills necessary for the normal acquisition of language for communication. Such programs are known as Aural/Oral Rehabilitation programs, and despite their superficial differences, these programs all focus on developing hearing and listening skills in the hearing impaired child in a natural way

What is Aural/Oral Rehabilitation?

The great advances made in hearing aid technology and in cochlear implant surgeries have now provided many hearing impaired children with the opportunity to learn to hear and develop language skills; oral/aural rehabilitation is the therapy technique adopted to train these children to use their residual hearing to acquire language to communicate.

The proponents of the principles of aural/oral rehabilitation believe that teaching children to use their hearing to learn to speak will help them function more effectively in a hearing society and will provide them with the skills needed for education.

Aural/oral rehabilitation is especially important for children with hearing impairment in the Middle East, because there is no other viable option for communication as there is no established universal Arabic sign language yet.

However, Aural/oral rehabilitation is not the only therapy available for hearing impaired children; children with hearing impairment can also be taught to communicate using total communication, which uses gestures (signs), lip reading, and writing; sign language is another system for communication, however, as mentioned earlier, sign language has not been unified in the Middle East, and is not a comprehensive language system such as the American Sign Language (ASL) or the British Sign Language, rather it is a system of communication that is comprised of common gestures. However, total communication and sign language are the treatment of choice when the child has no benefit from the hearing aids as a result of a profound hearing loss.

The Fundamental Principles of Aural/Oral rehabilitation:

  1. It is important to encourage the child to use oral language to communicate. To achieve this, the therapist and the family must talk to the child and not use gestures and signs as these are not accepted in the aural/oral method.
  2. It is very important to identify the hearing loss as early as possible and to fit the child with the appropriate hearing aids, FM system, or to have the child undergo cochlear implant surgery if it is indicated. The earlier the child can receive amplification the sooner he/she will be exposed to sounds and spoken language, the better his/her chances to acquire language. These early years of development are crucial. The audiologist is the specialist who diagnoses the hearing loss and recommends the appropriate hearing aids. Each child is fitted with the hearing aids that are suitable for his/her individual needs. If surgery is recommended, the child will be referred to an ear nose throat (ENT) specialist for further investigations and the family will begin the process for the cochlear implant surgery. The aim is to provide the child with the maximum possible amplification in order to facilitate his/her sound recognition as soon as possible.
  3. It is important to develop a partnership between parents and the therapist; the parents must receive training in the aural/oral rehabilitation method. They will need to learn how best to create an environment at home that will be conducive for their child to learn to listen and how to encourage him/her to use spoken language to communicate the child needs. They become their child's advocates for oral language. They will need to educate all those around their child not to use "soundless" talking, nor to use gestures, nor shortened, ungrammatical sentences. 
    Parents will be required to attend the therapy sessions with their child to become more informed about the method and their role in the learning process of their child. With training and counseling, the parents become the "specialists" at home, and they learn to implement all the strategies from the therapy sessions in the day to day life of their child. This intensive and systematic carry-over is the principal key to the development of the listening and speaking skills of their child.
  4. An individual therapy plan will be designed for each child and his/her parents, according to the child's specific needs. The role of the therapist will include training the parents and counseling them on how to implement the aural/oral rehabilitation strategies to create a listening and speaking environment that is natural for their child.
  5. The aural/oral therapy focuses on developing the child's spoken language through listening and hearing. During this process, the hearing impaired child learns to listen to his/her own voice, and learns to imitate the speech of those around him/her in the same manner as normal hearing children do. The child begins to coo, then begins to babble, to approximate the sound of words, eventually, he/she produces single words and finally begins to make short sentences. The child is not specifically trained to lip read, however, he/she develops this skill naturally from their daily exposure to spoken language and observing the facial expressions of the speakers.
  6. The parents should create a natural learning environment at home in which the child learns how to participate in the daily chores and duties within his/her family nucleus and listening becomes integrated into all daily activities so that it becomes a way of life. The family is encouraged to treat their hearing impaired child in the same way as their other children by including him/her in all their activities.
  7. The therapist guides the child through the natural developmental milestones necessary for the acquisition of hearing, speech and language skills. The aural/oral rehabilitation program focuses on teaching the child to be attentive to the different sounds that stimulate the areas of the brain that process hearing, and stimulate language which ultimately promotes oral communication. As the child's ability to discriminate between sounds increases and his/her auditory memory improves, his/her vocabulary, phrases, and sentences begin to expand. The family is encouraged to use daily activities and events to reinforce the child's listening and language skills. 
    The child's first years are crucial in establishing the listening and hearing foundations necessary for oral communication.
  8. A hearing impaired child's hearing loss can change during the early years of development. Therefore, it is important to monitor his/her hearing to ensure that the hearing aids remain adequate and that the ear molds are still fitting properly. Additionally, the child's progress in the treatment program is continuously assessed and adjustments to his/her treatment program are made accordingly in partnership with the parents.
  9. The parents of the hearing impaired child in the aural/oral rehabilitation program are encouraged to enroll their child in a preschool for normal hearing children. While attending the preschool, the hearing impaired child will socialize and play with normal hearing peers, these children will serve as a model for his/her thus, reinforcing the listening and language skills learned in therapy.

The key requirements for the success of the Aura/Oral Rehabilitation Program

The success of the aural/oral Rehabilitation Program depends on the availability of a hearing environment, the correct implementation of the rehabilitation program and the participation of the family.

A- The hearing environment:

In the aural/oral rehabilitation program the child learns spoken language through listening and hearing, and not through seeing. Therefore it is important that the training takes place in an environment that encourages listening and facilitates understanding instructions which promotes learning.

To encourage listening:

  • Sit in close proximity to the child (on the side of the better ear)
  • Talk from a close proximity to the child's hearing aid or his/her cochlear implant
  • Talk to the child in a natural way (avoid shouting or using gestures)
  • When talking to the child avoid sitting in an area where there is background noise (television, air-conditioning etc)
  • Use a singsong voice, this type of voice is rich in acoustic information, it conveys happiness, sadness, etc; in this manner the child with hearing impairment will learn to speak with the appropriate intonation
  • Use acoustic highlighting when introducing new words; emphasize the new word by making it louder than the rest of the sentence

B – The treatment program:

The aural/oral rehabilitation sessions provide on going diagnostic assessment through observation and evaluation, and an opportunity to counsel the child's parents. During these sessions, the therapist assesses the child's listening and hearing skills as well as his/her interaction with the parents. These sessions can take place in a clinical setting or in the school. The therapist can use the child's own toys and household toys to encourage conversation with the child through listening and hearing.

Most aural/oral rehabilitation sessions are an hour to an hour and a half long weekly. The aim of these sessions is to train the parents on developing the necessary strategies and techniques they will use daily in their home with their child to develop them for spoken language. Through their training with the therapist, the parents develop the confidence to work at home with their child to help him/her achieve his/her hearing and speaking goals in the most natural way. In addition to these individual sessions, the child might also attend group sessions with other hearing impaired children. In these sessions the child works towards specific goals such as learning to communicate appropriately with his/her peers.

Together as partners, the parents and the therapist set specific goals for the child to work on at home. For young children, these goals will be achieved through play with toys, makeshift household items and through the child's daily chores and activities. For the older child, the training to listen and speak will be through story telling, holding a conversation with the child in a naturally noisy environment and through discussing his/her school work and expanding the conversation around the topics learnt during his/her school day. The child's listening and speaking experience should be appropriate to his/her age, ability and interest.

All the hearing and language goals are dependent on the language development level of the child and his/her hearing skill level. These hearing and listening skills are developed through play, daily routine activities as well as set activities, rhythms and songs.

C- The parent participation:

Children learn language more easily when they interact with people they have a bond with i.e. their parents, and while taking part in activities that they enjoy and that are meaningful for them in a comfortable and secure environment. For that reason, the parents' observation and participationin the sessions is very important, since they will be doing the carryover in the home. During the child's session, the following points are covered:

The therapist models the best method of communication to use with their child to promote hearing and language, and recommends the best language activities to use in the home.

  1. The parents learn how to introduce hearing, listening, speech and language goals in their child's daily routine activities .
  2. The parents learn to work with the therapist as partners in the rehabilitation program of their child.
  3. The parents keep the therapist abreast about their child's interests and abilities.
  4. The parents provide the therapist with valuable information about any emerging vocabulary and the first attempts of their child to communicate.
  5. The therapist counsels the parents on how to deal with any concerns they may have about their child's behavior.
  6. The therapist records and discusses with the parents any significant progress.
  7. The therapist explains the short term and long term goals of the treatment program.
  8. By regularly attending the treatment session, parents gradually develop the self confidence to work and deal with their hearing impaired child.
  9. The parents learn to make informed decisions concerning their child's treatment and education.
  10. The parents learn to advocate for and protect the rights of their child (for example: they do not allow others to use signs and gestures instead of spoken language with their child).

Factors that affect progress

Children and their families have different learning styles and each of them have their own individual family culture, and as a result, each hearing impaired child's hearing and language development varies from child to child, and their progress depends on several factors such as:

  1. The child's age when first diagnosed with the hearing impairment.
  2. The earlier the hearing loss is discovered the better the prognosis.
  3. The cause (etiology) or the type of hearing loss.
  4. The severity of the hearing loss.
  5. The efficacy of the hearing aids or cochlear implant.
  6. The efficacy of the audiology services provided.
  7. The child's general health.
  8. The emotional well being of the child and his/her family.
  9. The level of participation of the parents.
  10. The level of proficiency of the therapist.
  11. The parents' skills and ability to work with their child.
  12. The child's individual learning style.
  13. The child's cognitive ability.
  14. The ability of those persons dealing with the child other than his/her parents ( his/her friends the family)

© 2011 JISH Jeddah Institute for Speech and Hearing, all rights reserved.