Auditory Verbal Therapy Position Paper

Educational attainment 

Deafness is not a learning disability. Most children with hearing loss have the potential to reach the same educational outcomes as hearing children if they have appropriate support. However, if there is a language delay, this can affect both children’s literacy and numeracy. A study in 2017 funded by the Nuffield Foundation reported that 48% of oral children aged between 10 and 11 years were reading below age level¹⁶. Analysis of 2022’s GCSE results by the National Deaf Children’s Society shows that deaf pupils in England have now achieved an entire GCSE grade less than hearing peers for at least seven years in a row. Just 37.7% of deaf children gained a grade 5 in key subjects English and Maths, compared to 49.8% of hearing children¹⁷. Similar analysis for Key Stage 2 results showed that only 40% of deaf children achieved the expected standard for reading, writing and mathematics at Key Stage 2 compared to 59% of all children ¹⁷.

 

Deaf pupils in England have now achieved an entire GCSE grade less than hearing peers for at least seven years in a row¹⁷

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However, a population study of the emergent literacy skills of pre-schoolers found that children enrolled in Early Intervention before age 6 months had consistently higher scores in emergent literacy components over time compared with children enrolled at or after age 6 months¹⁸, highlighting the importance of effective early intervention.

 

Figures show that deaf children are not ‘catching up’ from their lower starting points as they move through secondary school¹⁹. Furthermore, an early language delay can continue to jeopardise future educational outcomes for deaf children.

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Disadvantages

Children who have hearing loss are also at greater risk of experiencing social isolation, loneliness and difficulty with peer relationships^19,20. This influences later adult relationships and social emotional development. Early access to language is the decisive factor that drives development forward and provides good social-emotional functioning²¹. With over 40% of children with permanent hearing loss estimated to have mental health difficulties in childhood/early adulthood²², there is a vital place for effective, family centred, early intervention.

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 Auditory Verbal therapy and outcomes

The term Auditory Verbal therapy was coined by the Alexander Graham (AG) Bell Association for the Deaf in the 1970s in the United States²³. A systematic review published in 2021²⁴ and 2023²⁵ suggests that there is strong evidence of the effectiveness of Auditory Verbal therapy on the development of all linguistic skills. One specific study in 2021 found that good attendance at Auditory Verbal therapy sessions was a factor that led to better spoken language outcomes ²⁶

 

There is strong evidence of the effectiveness of Auditory Verbal therapy on the development of all linguistic skills

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Listening

Optimal development of speech and language skills is preceded by developing optimal listening skills. Listening is dependent upon the stimulation and development of the auditory cortex in the brain. Throughout the first three years of life, children generally receive this stimulation in the form of interactions with their parents and this allows them to start learning language²⁷. We now know there is a sensitive period during which the central auditory system remains maximally plastic. An effective early intervention programme, comprising optimally fitted hearing technology (i.e. hearing aids or implantable hearing technology, such as cochlear implants) together with effective early support for communication needs to be in place as early as possible and ideally within the first three and a half years in order to optimally support the brain development required for listening and spoken language development²⁸. Research has shown that children who receive a cochlear implant below the age of 2 years old obtain higher mean receptive and expressive language scores than children implanted over the age of 2 years²⁹.

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Overwhelming Evidence

The evidence base for the effectiveness of the Auditory Verbal approach is growing with more research being published every year. Outcomes for a group of more than 200 children who have followed either an Auditory Verbal, a total communication or an oral (listening with an intentional support of lipreading) approach has found that children following an Auditory Verbal approach outperform children who have followed an oral or total communication approach on a number of measures including speech-language, speech intelligibility and literacy³⁰. A further analysis of a greater number of Auditory Verbal interventions has been conducted to highlight both their effectiveness and to direct future research³¹. Other research, albeit more limited, has also indicated that there are benefits of choosing an Auditory Verbal approach, even after the optimal intervention age. For example, late identified children have shown social interaction skills comparable to their hearing peers after Auditory Verbal intervention³². In the UK, the Early Intervention Foundation has independently assessed the evidence from the research base and included Auditory Verbal therapy in its guidebook for commissioners of Early Intervention programmes³³

 

Deaf children following an Auditory Verbal approach outperform children who have followed an oral or total communication approach

 

Research from the US and Australia shows that children in an Auditory Verbal therapy programme develop spoken language in line with their hearing peers^34,35,36,37, and progress at the same rate for listening, spoken language³⁸, self-esteem, reading and mathematics as a matched group of children with normal hearing³⁹. First Voice, a consortium of Australasian Early Intervention Centres (of which Auditory Verbal UK is an international member) collate and publish spoken language outcomes for graduates of Auditory Verbal programmes. The First Voice consortium has published the Sound Outcomes report for 2021 in which data was pooled over five Auditory Verbal programmes. Reporting on 186 children with hearing loss who graduated from First Voice centres in 2021, 83% of graduate children with hearing loss alone (i.e. without additional difficulties) achieved a standard score within or above the average range for typically hearing children⁴⁰. The report also details a cost benefit analysis from 2019: the benefit to cost ratio for the community investment was approximately 4:1, a figure replicating Auditory Verbal UK’s own cost benefit analysis in 2016⁴¹.

In 2022, the Danish government announced that AV therapy would be included as part of the care pathway for all children up to five years of age with permanent hearing loss. This followed a government funded project to investigate the effectiveness of the AV approach in a national intervention study for the families of children with a permanent hearing loss aged from birth to five years. Aiming for the goal of age-appropriate speech-language skills, the evaluation reports that 84% of the children achieved age-appropriate spoken language after three years of AV therapy. The figure was previously only 30%⁴².

 

Recent research (2018) investigating the early reading development of children with cochlear implants who have followed an Auditory Verbal approach has found that phonological awareness, the awareness of the sound structure of language, is a significant factor in reading development⁴³. A 2020 study from the USA found that children with hearing loss aged from 5 to 9 years, who used a listening and spoken language approach, demonstrated reading skills within the average range for typically-hearing individuals through the use of hearing technology and appropriate intervention⁴⁴. Regarding further chronological development of reading, research from Israel has shown that Auditory Verbal therapy graduates outperform adolescents and young people with hearing loss who were not rehabilitated via this approach, in Hebrew and Literature grades⁴⁵.

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Outcomes in the UK

 

80% of all deaf children who spend at least two years on our programme at Auditory Verbal UK achieve age-appropriate language

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In the UK, approximately 80% of all deaf children who spend at least two years on our programme at Auditory Verbal UK achieve age appropriate language⁴⁶ and most attend mainstream school⁴⁷. On average, deaf children with additional needs double their rate of language development whilst on the Auditory Verbal UK programme, and one in two children reach age-appropriate spoken language at the end of their programme⁴⁶. This suggests that Auditory Verbal therapy continues to be an effective intervention even if a child has additional needs. For children both with and without additional needs, the earlier they start the programme, the better the prognosis for language development^46,48. The target-focussed, collaborative approach adopted by Auditory Verbal practitioners⁴⁹ influences the outcomes for families of children who have hearing loss alone and of those who have additional challenges⁵⁰. The holistic approach of Auditory Verbal intervention promotes best outcomes through transdisciplinary working.

 

In AVUK’s 2018 study, it was shown that 97% of deaf children without additional needs reached at least age-appropriate spoken language at the end of their Auditory Verbal therapy  programme⁴⁶.

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Educational outcomes 

 

Evidence of the literacy outcomes attained by deaf children in the UK whose families had chosen a listening and spoken language approach and accessed Auditory Verbal therapy were collated by AVUK in 2022. The research shows that most deaf children following the Auditory Verbal therapy programme are attaining educational outcomes on a par with hearing children. 

 

Over 80% of deaf children who have followed an Auditory Verbal approach, are reaching or exceeding nationally expected standards at Key Stage 1 for Reading, and Mathematics. Over 75% are attaining or exceeding these standards for Speaking and Listening and for Grammar, Punctuation and Spelling. At Key Stage 2, the percentages of children reaching or exceeding nationally expected standards were 81% and 78% for Reading and Mathematics, respectively. The percentages of children reaching or exceeding nationally expected standards for Grammar, Punctuation and Spelling was over 75% and 76% for Science⁵¹.

 

By considering these outcomes in light of the national attainment figures for, first, children with no special educational needs [figure 1] and, second, all deaf children [figure 2], we see that the percentage of graduates from AVUK achieving competency as measured by the national SATs is at a level at least equivalent to their hearing peers. This data includes data of children with additional needs.

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Nasir’s story

Abdul and Shamaila, Nasir’s parents, found out their son was deaf just before he turned one. There were desperate for more support as they were unsure what the future would hold for Nasir. They found AVUK through their Teacher of the Deaf and signed up for our Auditory Verbal therapy programme where Nasir learnt to listen and speak. Now, aged 17, Nasir is thriving, studying Business Studies at college. 

“Auditory Verbal therapy has given Nasir the ability to express himself amongst his family and peers. When we think back to those early days of anxiety and worry about Nasir’s future, we wish we could go back and tell ourselves that it was going to be alright.” – Nasir’s parents, Abdul and Shamaila

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Auditory Verbal therapy via telepractice

Telepractice is the delivery of services using telecommunication and online internet technology to remotely connect clinicians to healthcare providers for assessments and intervention. 

Research has shown that children with hearing loss who, together with their parents, receive telepractice sessions perform at least as well in multiple measures of language outcomes as those who receive in-person sessions⁵². Furthermore, parents have been found to be more engaged during teletherapy than traditional sessions^52,53,54 and may also favour telepractice because of the reduced disruption to their everyday routine^53,54. Telepractice also breaks down geographical barriers and facilitates global communication⁵⁵.

 

Telepractice had been used at AVUK on an ad hoc basis for more than a decade when the global pandemic of the COVID-19 began in early 2020⁵⁴. In March 2020, following the social restrictions imposed due to the global pandemic, all families at AVUK received therapy via telepractice. An audit of their experiences with telepractice found that approximately 80% of parents felt their child was making good progress with telepractice sessions, while 89% of therapists felt that telepractice sessions were equally or more effective than in-person sessions⁵⁴. Additionally, 85% of parents opted to continue with their Auditory Verbal sessions solely via telepractice or a blend of telepractice and in-person sessions⁵⁴. With appropriate technology, telepractice is a viable means of providing Auditory Verbal therapy⁵⁵. In 2022, AVUK  continued to see families both in person (34%), via telepractice (42%) and as part of a blended programme of both in-person and telepractice sessions (24%).

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85% of parents opted to continue with their Auditory Verbal sessions solely via telepractice or a blend of telepractice and in-person sessions following the COVID-19 pandemic.

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Maci’s story

“We are absolutely over the moon with how AVUK and the therapy has supported Maci and us as a family. It makes so much sense and everything we learn we use every day with Maci as well as sharing the details with family and Maci’s nursery so they can support too. It doesn’t put too much pressure on Maci either as it is all play – not like a ‘lesson’ at all.” - Nicole, Maci's Mum.

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Supporting families

Optimal language acquisition depends upon engaged parents ^56,57,58,59. Permanent hearing loss extending beyond the early school-age years without adequate auditory stimulation may result in significant re-organisation of the brain, with additional areas of the auditory cortex becoming involved in visual processing^56,60. If parents desire listening and spoken language outcomes for their child with hearing loss, a communication approach that emphasises early development of auditory brain pathways through listening and spoken language is necessary^6,60.

The Auditory Verbal approach puts families at the centre of the programme

 

The Auditory Verbal approach puts families at the centre of the programme which is focused on parent coaching. The Listening and Spoken Language Specialist Auditory Verbal Therapist (LSLS CertAVT) has been trained to develop individualised programmes to meet both the needs of the child and the learning style of the parent(s). Therapists at AVUK are involved in programmes of continuous professional development and are skilled in supporting parents through their child’s communication journey.

Over the last two years, AVUK has contributed to the International Family Centred Early Intervention for Deaf and Hard of Hearing (FCEI-DHH) Consensus Panel in reviewing the FCEI-DHH Principles first published in 2013⁶¹. These are due to be published in late 2023. 

A Danish study of parental perceptions of Auditory Verbal therapy found that almost all participants showed increased confidence in their ability to support the development of their child’s listening and spoken language as a result of participating in an Auditory Verbal therapy programme⁶². This finding is in line with the findings of Wolfe et al (2021)²⁶ This level of parental self-efficacy is consistent with that of the parents on our Auditory Verbal therapy programme at Auditory Verbal UK, with 97% of parents reporting that they felt confident in using Auditory Verbal techniques in their everyday life.

 

97% of parents report they felt confident using Auditory Verbal techniques in their everyday life

 

Partnerships between parents and professionals are essential. A primary school in Newham, East London, heard about the work being done by AVUK helping deaf children fulfil their potential and wanted to explore how they could further support deaf children entering education. AVUK provided training to staff at the school, which serves an area of high deprivation, helping them put families at the centre of their work and supporting parents and caregivers in learning how to make the most of every language opportunity. The headteacher at the time noted that training in and using Auditory Verbal therapy supported stronger relationships with parents and, together with staff, they became partners in supporting deaf children develop listening and spoken language in everyday activities.  Supporting the children and their families via the specialist provision of certified Auditory Verbal practitioners to facilitate the development of age-appropriate speech, language and literacy skills in profoundly deaf children, continues to be validated by independent research^25,31,51. 

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David’s story

 

“AVUK changed our lives. It has been the best intervention for David’s speech, language, socialisation and development skills and AVUK has been amazing so helpful and supportive every step of the way.” - David’s Mum, Irina.

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Auditory Verbal therapy across cultures

The Auditory Verbal approach is known across the globe. The Alexandra Graham (AG) Bell Academy is the accrediting body for certification to practice as a Listening and Spoken Language Auditory Verbal practitioner. In 2017, the AG Bell Global Matters Committee was established with the main purpose of supporting professionals globally who are interested in enhancing their listening and spoken language knowledge and practice for the benefit deaf children around the world. AVUK trains speech and language therapists, audiologists and teachers of the deaf from nations around the world. AVUK has trained professionals in more than 200 different countries. 

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Multilingual deaf children 

 

AVUK signposted some of the multilingual families on our AV programme to participate in a research project conducted by Emily Wright in 2021-2022 from the University of Reading. One aspect of the study examined the beliefs of professionals on the ability of a deaf child to acquire two spoken languages and the advice professionals give to parents considering spoken language bilingualism for their deaf child. In an evolution of practice over the last decade, most participants believed deaf children can achieve spoken language bilingualism and would advise parents to speak in their home language, regardless of the parents’ English proficiency. This is supported by evidence from families attending AVUK^36,63,64.

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Lola’s story

 

“Having that intensive input during that important window of opportunity to develop language means we are now in a place we never thought we would be and couldn’t have achieved without AVUK. Lola is bilingual French and English and starting to learn Spanish. She loves music and dancing, is confident, has a great sense of humour and we can’t wait to see what the future holds for her.” - Lola's Mum, Gina.

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Provision and funding across the UK and world

The international evidence in this Position Paper demonstrates that deaf children in the UK could benefit greatly from an investment into making Auditory Verbal therapy more widely available in the critical first few years of a child’s life. Yet the UK currently lags behind many other countries in providing investment in and access to Auditory Verbal therapy.

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Provisions across the world

 

There are currently over 1,000 certified Auditory Verbal therapists worldwide, with this form of early intervention being government-funded in Australia, New Zealand and Denmark. It is also a mainstream approach in North America for enabling deaf children to listen, speak, and to achieve long term social and educational outcomes⁴⁶. In 2022, following a successful government-funded pilot programme, Auditory Verbal therapy became part of the standard healthcare system in Denmark.

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In the UK

 

92% of deaf children who could benefit from Auditory Verbal therapy are currently unable to access it

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In the UK, there is a lack of awareness of what deaf children can achieve, with only 2 in 5 (41%) adults believing a child born profoundly deaf can learn to speak as well as a child without hearing loss⁶⁵

 

In addition, there is little to no provision of Auditory Verbal therapy through the NHS and local services. This is because there are currently only 30 Auditory Verbal therapists in the UK as of September 2023. Eleven of these therapists work for AVUK with others based in the National Health Service (NHS), local authorities and in private practice. With full caseloads, these UK-based therapists can only provide therapy for less than 10% of the deaf children under 5 years old in the UK.

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Training professionals

 

To increase access to specialist support, there needs to be more practitioners trained in Auditory Verbal practice working in the NHS and Local Authority Sensory Services who support deaf children across the UK.

 

Auditory Verbal UK provides internationally accredited training for speech and language therapists, audiologists and teachers of the deaf who wish to become Auditory Verbal practitioners to address this severe need. AVUK have supported 12 UK professionals to become certified Auditory Verbal Therapists, and 16 across the world. As of September 2023, AVUK has 44 professionals, including 17 from the UK enrolled on our foundation courses, and 26 professionals including 7 from the UK on our advanced courses working towards certification.

 

In 2019, the National Institute for Health and Care Excellence for England and Wales put forward new guidance for cochlear implant candidacy criteria. The guidance promotes babies being screened within one month, referred for hearing aids within two months and referred for cochlear implantation within a year. If we are to benefit from the investment into early intervention, we need to enable our current public sector workforce to equip parents and carers with the techniques and strategies they need to maximise the potential of their child’s hearing technology and listening and learning skills.

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Investment needed

 

Investment of just over £2 million a year for the next 10 years will unlock £152 million of economic benefit, rising to £11.7 billion within the next 50 years

 

Economic analysis shows that an investment of just over £2 million a year for the next 10 years to train a small proportion of the current public sector workforce and embed at least 300 specialist therapists within the NHS and local services, while delivering direct support to the most vulnerable children and families, will transform services for deaf children. This investment will unlock £152 million of economic benefit, rising to £11.7 billion within the next 50 years, through improved quality of life, employment prospects, lower costs of schooling and avoided injuries.

 

We can and should raise the expectations of deaf children and unlock significant educational, social and economic benefits for the UK⁶⁶.

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Ava’s story 

“I hope that one day soon, many more deaf children will have the same opportunities in life as me, and Auditory Verbal therapy will be available to all families who want it. When I was a baby, my parents found out that I had a profound hearing loss. They didn’t know what the future would be like for me. AVUK has really shaped me into the person I am today and given me the chance to have amazing everyday experiences. I attend a mainstream school, enjoy learning piano and saxophone and have ambitions to be a film director.” - Ava, 16

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Orson’s story

“Being deaf is part of who I am and it has never stopped me doing anything I want to. It isn’t fair that all deaf children don’t get the same opportunities that I have had, and I really hope the Government listen to us, so every deaf child gets the support they need.” - Orson, 9

Orson, pictured on left with his family

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Take action

 

Our family programme for deaf children.

 

Our professional training programme.

 

Write to your MP and ask them to help increase access to and investment in Auditory verbal therapy.

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References

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*The term ‘deaf’ is used in this paper to denote an average hearing loss of 40 dBHL or greater in the ear most sensitive to sound.

 

**The term ‘parents’ refers to any significant caregiver in the child’s life.

 

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65. Auditory Verbal UK (2023) The research shows that only 2 in 5 (41%) UK adults believe a child born profoundly deaf can learn to speak as well as a child without hearing loss. All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 2078 adults. Fieldwork was undertaken between 30th – 31st March 2023.  The survey was carried out online. The figures have been weighted and are representative of all UK adults (aged 18+).
66. Economic analysis, carried out externally on a pro-bono basis 2021

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