#016: How to Support Students with Hearing Loss

Marisha: Hey, guys. Welcome to the SLP Now Podcast. I am so incredibly exited to be chatting with Lauren DiBiase today. Lauren is an ASHA-certified speech language pathologist, and she's also a certified LSLS auditory-verbal therapist. If you don't know what LSLS is, like I didn't, it's a language and spoken language specialist. She is also a teacher author, so very busy, accomplished SLP here. She began her career in a school for the deaf before transitioning to the New York City Department of Education where she now works in the largest special education district in the United States.

Marisha: her passion for creating and sharing resources, paired with her devotion to supporting students with special needs has led her to create her Teachers Pay Teachers store where she offers a variety of amazing resources to help all of us busy SLPs serve our students. We will link to her store in the show notes, in case you want to check that out.

Marisha: But without further ado, let's hear from Lauren and dive into all things hearing.

Lauren DiBiase: Hi, Marisha. Yes, thank you so much for having me on your podcast. I'm really excited to be here and talk to all of people who listen to you.

Marisha: I'm especially excited, because we've been getting a lot of questions about this population. I've dabbled a little bit, just enough to get dangerous, but I just knew that you would be the perfect person to break down these different questions. So I can't wait.

Marisha: But before we dive into all of the logistics and all of the strategies and juicy tips, I'd love to hear a little bit about your experience as an SLP. We talked a little bit about where you work, but how did you end up learning so much about working with students with hearing loss? How did you fall into all of those different certifications? That entire process would be amazing just to get a quick glimpse at all of the goodness.

Lauren DiBiase: Yeah. So I always had a very strong interest in American Sign Language. I try to think back to when did it start, and growing up, I would go to camp, and we would learn songs in sign language. Then my very first job, I worked at T.J.Maxx, and I remember there was an interaction with a customer who was deaf, and we just could not understand one another. The customer was frustrated, and I felt terrible. So that kind of encouraged me as soon as I started college to sign up for ASL 1.

Lauren DiBiase: My college, Hofstra University, they offered ASL 1 through 4, but when I finished it, I wanted to learn more. So I signed up for night school. It was an adult continuing education deaf studies certification, which led me through ASL 1 through 8 and Deaf Studies and Deaf Culture. It really gave me a strong background in that area, while taking speech language pathology classes.

Lauren DiBiase: So I graduated with a bachelor's in Speech Language Hearing Sciences, but also with this Deaf Studies certification. Then when I graduated with my master's, I really wanted to find a way to kind of combine my love of ASL and my love of speech language pathology. So I managed to get a CFY at this school for the deaf after applying to over 60 positions. I live in a place where it's really hard. There's just no jobs.

Lauren DiBiase: On the interview, they asked me if I would be willing to start going for AVT certification. I had no idea what it was, so of course I said, "Absolutely. It's something I'm very interested in." That's kind of how I got started. Once they hired me, I found out what AVT certification was. It's basically a certification through AG Bell, the Alexander Graham Bell Organization. It helps SLPs or a teacher of the deaf or administrators become specialists working with children who have a hearing loss who want to go down the pathway of learning to listen and then listening to learn. It's a four-year process. You have to take over 100 hours of continuing ed... I'm sorry, CEUs. You have to have a mentor. You need to have any hours documented of working with children who are deaf or hard of hearing.

Lauren DiBiase: Then after all of these requirements, after you meet them, there's a very large exam. Then when you pass the exam, you become certified. So it's kind of unusual to have an auditory-verbal therapist who is bilingual in American Sign Language, but here I am.

Marisha: That is so amazing. I had no idea that... It's like a second CF almost. That's a lot of extra...

Lauren DiBiase: It is, yes.

Marisha: That's amazing. That's so cool. That makes it even more special for us to hear from you.

Lauren DiBiase: Thank you.

Marisha: Okay, so now let's get into some of the tips. So I think a lot of us are just struggling knowing where to start. I think one of the easiest ways to kind of start talking about it is how can we even identify these students on our caseload? Maybe if they don't even have a diagnosed hearing loss yet, what steps can we take to be proactive there? How do we know what to look for?

Lauren DiBiase: That's a really great question, because a lot of times children are going unidentified, despite the newborn hearing screening that's now in place in all hospitals in the USA, for a variety of reasons. Sometimes they're passing when... They're falsely passing these tests, or maybe they're not passing, but the parents are not bringing them back for the second appointment. I know where I work, I have a large number of students who have recently immigrated from other countries where they don't have a newborn hearing screening. So they were not screened, and they missed noticing that their child has a hearing loss.

Lauren DiBiase: So here's a couple of ways that you might start getting suspicious that maybe your student should go for a screening or for a full audiogram. It's important to remember that these things you might be noticing, they're also seen in children with other special needs, such as autism or a language disorder. That's why if your kid has one or two of the things I'm naming, it's not such a red flag, but if you're seeing seven, eight, nine, then I'd start to look more into it.

Lauren DiBiase: So things like the child is not responding to their name or not turning or reacting to loud noises, and obviously you can sabotage this by dropping something heavy and seeing if they're turning. In terms of their speech, this gets a little tricky, because our schools have trained us, "Oh, if a child is omitting the S, maybe they have final consonant deletion, or maybe they just can't say the S. That's why they're not using it."

Lauren DiBiase: But if a child is omitting S, F, S-H, those high frequency sounds, that is a red flag, or if they're omitting morphological markers, like plural S, possessive S, the past E-D, those sounds, again, like in school, we're taught that they're morphemes, but we're never really taught that those sounds are not acoustically salient. So those are the sounds your kids with hearing loss are not going to pick up. If they can't hear them, they're not going to use them.

Lauren DiBiase: Children with hearing loss also often they'll skip the function words. So the words and, the, or. Again, those words are not as acoustically salient as content words. What else? Oh, N and M. if they're confusing those, again, I never learned this in school, and I so wish that I had, those sounds, there's something called a nasal murmur. Kids with hearing loss will frequently confuse those two sounds.

Lauren DiBiase: Kids with hearing loss are your kids who might sound robotic. Again, this could be a sign of a kid with autism, but it also could be a kid with hearing loss. Poor intonation, poor rhythm, poor volume modulation, those are all red flags. Also, if they don't socialize well in noisy environments or if they look like they have poor attention, that could be an attention deficit, but it could be hearing loss.

Lauren DiBiase: Then your kids who have difficulty following directions, it's a red flag. The only other thing that I really can think of that's a huge red flag is your kids who are always out for ear infections. Are they rubbing their ears? Is there discharge? Then of course if there's a family history, if you meet a parent and you see that the parent has a hearing loss, that also would be a cause for a potential questioning about whether maybe your student has a hearing loss.

Marisha: Yeah. So helpful. I really like that breakdown of things that we notice and see all the time, and just kind of keeping that in the back of our heads. Okay, if we're seeing that they're leaving off the Ss, or they're leaving off function words, or if we're seeing a number of those different things, just to remember that that's something else that we might want to look into.

Lauren DiBiase: Exactly.

Marisha: And being proactive can be incredibly helpful and an easy solution.

Lauren DiBiase: Yeah, and I think that... Oh, I'm sorry. Go ahead.

Marisha: No, go ahead.

Lauren DiBiase: I think that also I only had one class in my graduate program that touched on hearing loss. I think that might be pretty similar county-wide or worldwide that there's just... Because it's such a small niche. Grad school is just like survival. I feel like you don't even remember half of what you learn. I wish that there was just a little bit more attention given on it, especially with... I don't know about where you're from, but right now we're having a major measles out break on Long Island and in the city. So there's going to be an influx of kids with hearing loss coming into our school. So I hope that these red flags are helpful for your followers, know what to listen for.

Marisha: Yeah, no. I definitely took some notes and will kind of put that on a sticky note just to remind myself too, just to make sure, because we do have a lot of different things going on. It's especially great if we're feeling stuck on a student too, like, "Oh, why aren't they making progress?" Or whatnot, especially looking back at these things might help us identify something that we missed.

Lauren DiBiase: Yeah.

Marisha: Okay, so we have some really great strategies in our pocket now to identify these students. We know what to look for. Then we would typically... This will vary, depending on our districts and all of that, but there's typically a way to make referrals. There's typically access to an audiologist. They do hearing screenings and all of that. Do you have a little bit of insight into that process? Do you know if there's any generalizations or tips for success there?

Lauren DiBiase: I'm sorry, tips for success...

Marisha: When it comes to... Okay, so we suspect that a student has a hearing loss. Do you have any tips in terms of [crosstalk 00:12:24]?

Lauren DiBiase: Oh yes. Okay, in terms of tips, I definitely suggest trying to have a really strong rapport with your students' families, because that is who you're going to reach out to. I would speak first to your students team, their teachers, anyone else who works with them and see if what you're seeing is what they're seeing also. Then hopefully you do have that relationship with the parents that you can either call them or have a conversation face to face and talk about what you're seeing and how you feel that there's a potential that maybe something else is going on, and just to rule that out that you would recommend them go see an audiologist.

Lauren DiBiase: I always keep a sticky note of audiologists who are in my area, that way I have some direct numbers to give them. Obviously depends on their insurance, but yeah, the most important thing to actually getting your student to the audiologist is that relationship that you're going to have with the parent. You have to know them. Is it a parent who might become a little bit defensive? Because you don't want to suggest that the parent didn't pick up on this. So I always say things like, "We're taught to look for these signs. It's not something other people might notice, but we're taught to look for them." You don't want the parent to ever feel like, "Oh my goodness, how did I miss this, and someone who sees my student twice a week for 30 minutes noticed?" You want it to be more of like an open conversation where everyone feels comfortable.

Marisha: Yeah. Like we were talking about before, we can say how... It's easy to assume that it's something else that's causing those difficulties, whether it's a language delay or autism or attention deficit. There's so many other potential causes. It makes sense that it could be missed. There's obviously a reason why. It's not always super obvious, so I think that might help too.

Lauren DiBiase: Right, especially because our students who do have autism or a learning disability or a language delay, those are the kids who are especially difficult to test. So that's just another reason why it can go undiagnosed for so long. It can be hard for even audiologists to be able to determine sometimes if they're doing a behavior audiogram. It's difficult.

Marisha: Yeah. Yeah, that's super helpful. Okay, so now that we've identified these students, we know who has a hearing loss, what are some of the first things that an SLP needs to know if they do have a child with a hearing loss on their caseload?

Lauren DiBiase: So I try to put myself in the shoes of an SLP who works maybe in a school who has no hearing loss kids on their caseload, and then pop, one comes to district. The first thing I would say is do not be afraid. It's really intimidating to get a kid on your caseload with a diagnosis that you're unfamiliar with. So don't be afraid. There's a ton of resources online that I'm going to share with you guys, that way you just have a little bit of reassurance like, "Okay, I don't know what to do, but I know where to go to find out what to do."

Lauren DiBiase: ASHA's website is always amazing. AudiologyOnline is a website that I use, and it's $100 a month, and you can watch... There's hundreds of webinars on the topic of students with hearing loss. Then for your students who might be on the sign language track, there's ASLPro, there's ASL Savvy. Then for your students who are maybe on the listening and spoken language track, the AG Bell is a wealth of knowledge. So there's a ton of resources. There's even conferences. There's an AG Bell conference every year, and there's even a new conference. I think this is the second year for it, specifically for SLPs who sign and SLPs who work with students who sign. So the resources are out there. The very first thing is do not be afraid.

Lauren DiBiase: The second thing I would say is to accept that it's okay to have a lot of questions and to acknowledge that maybe you're not fully prepared to work with this student. It's okay to ask questions, and another resource for you, there's a Facebook group called Speech Pathologists Who Work With Hearing Impaired and Deaf Students Chat. I don't completely agree with that name, because hearing impaired isn't politically correct right now anymore. It should never have been. But it's a great resource, and all of the SLPs in that groups work with children who are deaf. So that's another great resource if you have a question. Everyone is really happy to help you if you reach out.

Lauren DiBiase: Okay, moving forward past that, I want to encourage you. I don't know if this is common. At my school, we have it though. The school gets a HIPAA release. If you have one, or if you don't, you can ask the parents, but this is one way you can find out your student's audiogram. That way you can see specifically what speech frequencies they're missing. What do they have access to without amplification? Or if they are amplified, what do they have access to with amplification? You can find out also have they been consistently mapped, if they have cochlear implants, and you can ask the parents what age they consistently started wearing amplification. These are all just tools that you can add to your tool belt so you can figure out where is this child starting at? What expectations should I have from this child? And you get an idea of how consistent is the family with appointments?

Lauren DiBiase: Also, right when you start out, again, I can't stress it enough, and I'm sure this is for all diagnoses, but since I'm kind of in the hearing loss field, family connection and relationship is so crucial, because you need to find out also what the parents' beliefs are. In terms of which path, I'm going to keep using that phrase, which path the ASL path or the listening and spoken language path, which path has your child's parents chosen?

Lauren DiBiase: It's important to identify if they've been appropriately educated before making that choice. That education will typically come from either EI or audiologists, or a prior SLP. So you want to find out why did your students' families make this choice, in terms of language modality? Was there education behind it? Was it an informed decision? Maybe the family is definitely. You need to know that right away before going forward, because you might... I find this really often that unfortunately, a lot of parents pick a path because they weren't given equal information on both. As an SLP, that's your role. So you may need to do that education if they haven't received it yet.

Lauren DiBiase: I think that it's important to remember when you first get a child with hearing loss that you're going to make mistakes, and especially this is with anything. If you're new to it, you're going to make mistakes, and it's okay to make those mistakes. But then when you learn something different, that's when you can change and put your new knowledge to use.

Lauren DiBiase: What else? I found that unfortunately there's a lot of misinformation since cochlear implants have become very popular. I think that unfortunately a lot of speech therapists and parents don't realize just how much work it takes from the whole team to make those cochlear implants be successful, in terms of having students be on age appropriate language levels. A lot of people choose cochlear implants, but then it's not followed through unfortunately. Then language deprivation happens, and then it looks like language delay.

Lauren DiBiase: But it's not the hearing loss that causes the language delay. It's the language deprivation. So you want to have open communication with your parents to make sure that that child is having so much language at home, be it sign language, be it spoken language, or if the child has additional needs, be it AAC. So parent education and also coming to the table unbiased. When I started in my school, I was so strong on the ASL. I had to learn that that's my view, and it might not be the view of everybody around me. So come to the table unbiased, but bring equal information about both options for your families and for your teachers.

Lauren DiBiase: You need to learn, don't be afraid to touch the amplification, the BAHAs, the hearing aids, the cochlear implants. You need to touch them and feel them and you yourself put them on and off the child to fully become comfortable using them and helping your child learn how to use them, because that's how you'll teach your students to advocate for themselves.

Lauren DiBiase: Also, once you know what kind of amplification your student is using and the company, you can go to that company's website for simple information on how to troubleshoot, because you're going to end up becoming the go-to person. You'll see if the hearing aid isn't working, someone's going to bring it to you, and you're going to pray it's just the battery. But maybe it won't be the battery. Maybe the mold is clogged. There's a couple of easy ways to troubleshoot. So I would definitely go to the company's website and learn how to do that also. That will give you a little bit more confidence.

Lauren DiBiase: What else should an SLP need to know if they have a child with hearing loss? Try to make your room as not distracting as possible. You don't want it to be so noisy if you are working with a child who is listening and spoken language. What else? You're going to want to see if the child... Again, if they're listening and spoken language path, you're going to want to see if they qualify for an FM system to increase the speech to noise ratio.

Lauren DiBiase: Oh, I know, Marisha, I really wanted to remember to tell your followers this, but if you get a student who has a hearing loss and they seem like their language is totally normal and their test scores are coming out that they're expressive and receptive is totally normal. I would encourage you to not discharge them right away, because one thing that a lot of people might not know is that children with hearing loss, they often struggle with things like subtleties of language, jokes, sarcasm. Also, we were talking about intonation and tone, things like that, and especially advocacy. So those are all things that you can work on in your speech room and you can make goals for that are kind of separate from that expressive and receptive section that a lot of people don't realize that is also... It's commonly seen in students with hearing loss that that is an area that they struggle with, and also listening and noise. So that's something you can work on with them also.

Lauren DiBiase: The only other thing I can think of is that when you get a new student and you're kind of reviewing their old speech file or their testing, just to remember that it might not be a true representation of their skills, because it is really difficult to sometimes test these students, especially students who use American Sign Language. There's just not enough standardized tests, unfortunately, for that population at this time. So you don't know exactly how they were tested, what it was based on, and if it was fair for them. I see a lot of kids coming in who use ASL, but the person who tested them wasn't fluent, and the score doesn't really reflect who they are as a person. You know what I mean?

Marisha: Yeah. That's a really good thing to keep in mind. Super helpful. Did you have any other strategies?

Lauren DiBiase: I think that when you're first starting with a child, I think that those are the most important things to try to keep in mind.

Marisha: Awesome. Super helpful. I'm typing away here like, "Ooh, I want to remember this and this and this." So thank you so much.

Lauren DiBiase: You're welcome.

Marisha: Before we dive into... These strategies are really helpful in getting started and just things that we can implement kind of on both ends of the spectrum, I guess. But can you, before we dive into more of the treatment strategies, can you break down the two different paths that you were talking about?

Lauren DiBiase: Yeah, absolutely. So I call it paths... I'm not sure if everyone calls it that, but it just is a nice, clear visual for myself, anyway, to understand. It's basically like the two language modalities. When I worked at my school for the deaf, there was kind of two tracks, to paths of classrooms. There would be classrooms geared for students who were going to become hopefully fluent users of American Sign Language, and that was going to be their language. Then there was a pathway, a track of classrooms where students would be put if their goal, their family's goals for them was for them was to become listening and spoken language users, so these were the students who were receiving that auditory-verbal therapy and classroom strategies, those were your students who, for the most part, were not being exposed to American Sign Language. Right now, with the trends that we're seeing, there is a lot more students who are placed on a track for auditor, verbal, and listening and spoken language than there are for students who are on an American Sign Language track. Again, this is for a lot of different reasons.

Lauren DiBiase: When a child, when a baby is diagnosed as having hearing loss, it's traumatic for the families. They go through a grieving stage, unless the family is deaf. A hearing family, this is not what they expected, and they go through those stages of grief. A lot of times they're bombarded with information about hearing aids and cochlear implants. They see success stories. But unfortunately, the success stories are not for everyone. There's a huge population right now of children who are deaf who don't know sign language because they're on that listening and spoken language track, but they have enormous, enormous language gaps for multiple reasons. One of the main reasons is that because they didn't get exposure to language early enough, because a lot of kids who receive cochlear implants, they don't receive it until nine months, 10 months, 11 months, 12 months. Sometimes they don't receive it until they're three or four, and they don't get full access with their hearing aids. A lot of children with hearing aids, they're not getting full access to the speech frequencies. How can you learn to speak and have verbal language if you can't hear it?

Lauren DiBiase: So I think, again, unfortunately, there's a lot of kids on that listening and spoken language track who should have not gone onto it, students who maybe had no hearing until they were five, and now they're given hearing aids, and it's late for them. Not everyone, but there's a large number of students who are in that listening and spoken track, because the parents are really just eager for their child to speak, but down the line, the gap grows bigger and bigger. That's why I was saying before, you need to have a family who is fully on board to follow through with every therapy strategy, with all of the appointments, with everything. It's a huge undertaking.

Lauren DiBiase: So the auditory-verbal track or pathway is very large and very full, and the track with American Sign Language is much less so, because the children who are on it might come from deaf parents, but that's unusual. There's not a huge number of children from deaf parents. It could be also children who are multiply handicapped. We see a lot of kids with cerebral palsy or autism on this track also, or there's a small number of children on the American Sign Language track. But it's kind of more like a total communication track, because parents who want both for their children are providing them with American Sign Language from birth, and that way there's no time, no gap in the language exposure.

Lauren DiBiase: They're also giving them listening and spoken language. So it's kind of like TC, they're getting both. It's kind of like... In this specialty, they call it bi-bi, like bilingual, bi-cultural kind of realm. So that's something we're seeing also. So when I say pathways, I'm kind of talking about the language modality and also the culture.

Marisha: Yeah, that's super interesting. Have you noticed anything different with... I don't know. I'm not totally familiar with all of the research in this area either, but is there... I think it makes sense. It's better to have something versus nothing, and so that the total communication path makes sense where you're combining both of them. But have you seen anything in the research comparing those paths, or just from what you've seen in your experience, in terms of kind of... It might be a little bit of bias there, in terms of your preference or what you want.

Lauren DiBiase: So there is more and more research coming out. It's a little bit difficult, and I'm not the... I'm sure there are people who can speak better on this than I can, but the research that I'm seeing is coming from sources that lean heavily. So I'm seeing research that is showing the benefits of American Sign Language from birth, and that being the child's L1. I'm seeing a lot of research coming out of Gallaudet, which is Gallaudet is a famous, famous university in Washington, D.C, and it's a deaf university. There are obviously huge promoters of American Sign Language.

Lauren DiBiase: Then I'm seeing research showing the importance of sole auditory-verbal therapy. When I say sole, I'm saying AG Bell, they believe in only exposing these children on this pathway to listening and spoken language. They discourage a child being exposed to American Sign Language. So research coming from them, again, you have to find kind of someone who's not from either... It's tricky, but I'm sure that there is hopefully research out there. I haven't seen it recently, but it could be there and I just haven't seen it.

Marisha: Yeah. It's so interesting. I know when I was going through school, we got to watch some different movies and documentaries. I think we even had some different guest speakers. This conversation is bringing back all of those discussions, because you have a lot of components here. It's kind of just like the nitty gritty of what we do, but then it's also that whole culture component is embedded with all of it. It just makes it a little bit trickier.

Lauren DiBiase: Yeah, it's super... I really think it might be the most controversial niche of our entire field. Sometimes it proves me wrong, because of course even though I try to keep it contained, there have been students in the past who I've worked with who have been... Say they come to me, they're two or three, and they're on that auditory-verbal track, and I'm like, "Oh my god, this child should be on the ASL track." Sometimes years later, I'm still confident that they should have been and a mistake was chosen for them. But then every once in a while there's children who are super successful with the auditory-verbal therapy because their parents really were on board. But for those kids who it didn't work for, they're going to have life-long challenges, because they just don't have the language, and that's really horrifyingly sad to see.

Marisha: Yeah. I can't even imagine navigating that.

Lauren DiBiase: So it's really difficult. Yeah, it's really difficult. That's why I keep saying you have to have a good relationship with the family, because if they've picked that auditory-verbal track but the kid is coming to school every day, and their hearing aid is dead, or their cochlear implant is missing, or it's in the backpack, you can tell this family either doesn't have the proper education to know what they need to be doing or the family is maybe too overwhelmed in a different area of their life to commit to this track. That's when you really need to educate them on American Sign Language.

Marisha: Mm-hmm (affirmative), wow.

Lauren DiBiase: Because at the end of the day when you take that cochlear implant off or the hearing aids off, you're standing in front of a child who is deaf. A lot of controversy in this area. If it was up to me, I would say TC all the way, total communication, ASL, and listening, spoken language, and you raise a bilingual, bi-cultural child, and that way when they get older, they don't feel like they're missing their identity. They're already part of the deaf community and they're part of the hearing community. I really just think it's the best of both worlds, and you've avoided language deprivation.

Lauren DiBiase: But then I remind myself this is very easy for me to say, because I'm already fluent. So I'm sure it's very challenging for people who have children who are deaf, and now they also have to learn a new language. But there's so many resources out there, and it is possible to do.

Marisha: Yeah. Because that's a really good mention there too. Do you have any favorite resources to help other people learn, like other people on the team? Because you mentioned ASLPro, ASL Savvy. Are those ones that you would share?

Lauren DiBiase: Yeah, those are great websites for learning single words, but of course single words are not a language.

Marisha: Correct.

Lauren DiBiase: I'm racking my brain. I know that there's a wonderful woman in SLP. Her name is Adrienne, and she does have an online class that I've heard is excellent. So I think her website is Learning with Adrienne, I feel fairly certain. I feel fairly certain. Besides that, I can't think of them, but I will go back and look. Then maybe we can just add them, add in a caption to this segment where people can go to learn more.

Lauren DiBiase: Also, local colleges most likely offer American Sign Language. The best way to learn, the very, very best way to learn is to learn from somebody who is deaf. I know my local library has classes from a deaf man. He teaches them, but depending on where you live, you might need to rely more heavily on the internet.

Marisha: Yeah. I actually took Adrienne's course.

Lauren DiBiase: Oh, how funny?

Marisha: Yeah, it's learnwithadrienne.com, and we'll also add that in the show notes. I think that course is more geared towards toddlers. So that would be perfect for those getting started, because the videos are just really top-notch and easy to go through. But I think it... I don't know. I think it would be amazing to have, but I guess it's still a good starting point, but the vocabulary is kind of geared more towards those younger kids, I think.

Lauren DiBiase: Towards young. Mm-hmm (affirmative), yeah. I'm trying to think. The best possible way to learn is definitely from somebody who's deaf. I follow a lot of people on Instagram, a lot of deaf teachers, deaf SLPs. Of course, right now, my brain is totally blanking on them. I know one of them is Adventures in Deaf Ed, but I'll look up the rest in my Instagram, and maybe we can add them also. There are a couple of people who are deaf who do teach common phrases on their Instagram. They post every single day, because you want to learn how to sign in fluency, in sentences and phrases, and not just word, word, word.

Marisha: Yeah. Yeah, and I think that's a really great idea, because then you just get little snippets of... Because that's how you learn any language is just taking a little, and some immersion in everything I think is definitely effective, but just getting those snippets on a day-to-day basis I imagine would help a lot too.

Lauren DiBiase: Definitely, because ASL, it's a little tricky. If you really want to learn Spanish, you can move yourself to a country that is Spanish-speaking or some other language, but ASL you can't do that so much, besides picking yourself up and moving to a community that has a lot of deaf representation. I know there's a huge community in Texas. There's a huge community in D.C, but it's not like... You're not going to go there for two months or three months. It's not as easy as picking up and going abroad to learn a language and emerge yourself. Immerse? Emerge? Immerse?

Marisha: Yeah, that totally makes sense. Then we definitely won't have time to dive into all of the strategies for all of the different paths. I wish to just magically disperse all of your knowledge, but do you have a few more tips that we can use when we're approaching treatment with these students?

Lauren DiBiase: Yeah, so I'm going to give general tips, like what you're saying. A lot of our children who are deaf or hard of hearing, they're so used to not being successful. It's very sad. So I always use extra, extra, extra positive reinforcement with this population, verbal praise, high fives, fist bumps, dances, stickers, a lot. You want any little thing that your student does with success, you want to praise it.

Lauren DiBiase: A lot of books, unfortunately, the average person who was deaf never gets past a fourth grade reading level. So you want to start exposure to literacy as fast as possible and encourage your students' parents to read them a ton of books also. Also, I know I keep mentioning advocacy, but I start my students right away. It doesn't matter if they're two, I use the correct names of their equipment right away. I don't call it, "Don't put your ears on." It's not an ear. It's a hearing aid. "Put your hearing aid on. What's wrong? Is the tubing..." You want to use words tubing, microphone, FM system, Roger, implant, magnet. You want to use the real vocabulary so that they can then use it, because when they leave your program and they have a new teacher or a new SLP, they need to be able to specifically tell the adult what's wrong, what's happening with their device.

Lauren DiBiase: Do not let them fake you out. Of all my students, my students with hearing loss are pros at following a familiar routine to hide and mask the fact that they can't hear the directions. So you need to try and sabotage them every once in a while. Instead of telling them, "Hang your jacket up or put your backpack on the floor," like you do ever single day, tell them something ridiculous, like, "Stand on top of your jacket," or, "Dump your backpack upside down," and see if they listened and heard you and they do it, or if they're following the routine.

Lauren DiBiase: What else is super important that I'm trying... Oh, multi-sensory approach for our kids with hearing loss. You want to have a lot of hands-on tactile activities. For your kids who are on that ASL path, I can't stress this enough, you want to give them role models. You want to expose them to other children or people who are deaf and use American Sign Language. There's books out there that show kids with hearing aids. I've seen people add hearing aids or cochlear implants using puffy paints onto dolls, baby dolls. American Girl I know makes a hearing aid, I think it's a hearing aid or a cochlear implant, I can't remember, that attaches onto the American Girl dolls. YouTube videos, there's so many YouTube videos now of children who are deaf signing fables and common stories. So you want to expose them to other people in the world who also use American Sign Language so that they don't feel isolated or they don't feel like they're not going to fit into the world. You know what I mean? You want to show them that there's other people out there who use sign language. Encourage the parents.

Lauren DiBiase: There's so many camps for kids with hearing loss, sleep-away camps. You want to encourage them to find other kids out there who are using the same modality and look like them also.

Marisha: Yeah, that's so helpful. I really like that. I think that's important. They talk about that community with a variety of different disorders or delays, because I know they have a lot of groups for kids who stutter and all of that. I think building that community and finding other kids who are like them is incredibly helpful and empowering too.

Lauren DiBiase: Definitely, yeah. I definitely agree with you. I'm trying to think if there was anything else. The only other thing I can say is, again, to use functional language. I stress this especially with your kids who are on the American Sign Language track. If you yourself don't sign and there's no interpreter at your school, to try really hard to learn as much sign as you can, and that way you're not just giving those content words.

Marisha: Mm-hmm (affirmative). Yeah. So you talked a little bit about the ASL path and what you would do there. Do you have any other suggestions for the auditory path? Do you have any ideas of how do you figure out where to start with that?

Lauren DiBiase: Yeah.

Marisha: Because I know you've talked a lot about bringing in parents and getting them on board, but I'm curious if you could give the listeners just a little bit of an idea of what that might look like.

Lauren DiBiase: Absolutely. So let's say a kid walks in, aided or has implants, and they're on that auditory-verbal track, and you're like, "I don't know what you hear." So there's something called the Ling Six, and I know we barely touched on this in school, and yet for those kids who are on that auditory-verbal track, the Ling Six is very crucial. It's these sounds, ah, ee, oo, mm, sh, ss, and those six sounds go across the speech frequencies. They hit the whole range. So if they can hear all six of those sounds, you can feel somewhat comfortable that the child hears all of the speech frequencies.

Lauren DiBiase: For children who are non-verbal, you're going to start to teach them how to, when you hear a sound, drop this item in a bucket. I use blocks usually. "When you hear..." Any sound, Marisha, "If you hear me clap," and obviously they can't see you at this point, you should be sitting behind them, if they hear a loud noise, "drop the block in the bucket. Drop the block in the bucket." You're going to start doing this hand over hand to train them to do it. Then you're going to do full tactile prompt, and then you're going to do a partial. Maybe your hand is just going to be on their elbow to prompt them to drop it when they hear the sound. Then you're going to slowly start moving away. After a while, and I mean a while, this could take a couple of sessions, they're going to figure out, "When I hear the noise, I'm going to drop it in the bucket."

Lauren DiBiase: Once they can do that, that's when you're going to do the exact same activity with the Ling Six sounds. So you're going to sit behind them somewhere that they can't see you. Also, preferably, if you have a mirror, you don't want to sit where they can see your mouth through the mirror, and you're going to say quietly those mm, ah, oo, one at a time. Mm, and then you're going to wait and you're going to see do they drop it in the bucket? I also do some empty sounds, because my kids are smart and they know there's six of them. You want to separate. You don't want to say a sound at the exact same increment, like every three seconds you're saying a sound. You want to space it out. You want to go quieter, louder, some times make no sound at all. Let me tell you, some of the kids are going to drop that block in the bucket, because they want praise, and they know it's expected of them, and that's when a kid is faking you out.

Lauren DiBiase: So once they can do those six sounds, the next thing, and I'm just going to jump into this really quickly, is that those sounds have associated items with them. So ah is an airplane. These are items that are always associated. Mm is an ice cream cone, on and on. Oo is a ghost. You're going to want the child to learn that ah is always associated with the airplane. So it becomes a matching. That's how they start to learn that sound has meaning, that that sound actually means an item. So that's where you start, Ling Six.

Marisha: That is super helpful.

Lauren DiBiase: Oh good.

Marisha: That makes so much sense.

Lauren DiBiase: Yeah, yeah. Obviously if their equipment's not working, you can't do that task. [inaudible 00:47:54].

Marisha: Yeah, because then, yeah, they won't be getting that in private.

Lauren DiBiase: Right. Exactly. One of the things, you never want them to leave on a down. Make sure that if they're having a hard time, you give them four that you know that they're going to get correct and then send them on their way, because it's hard. It's hard work. It's very difficult work for them.

Marisha: Yeah, I bet that's really tiring.

Lauren DiBiase: Yeah. It is. It's super tiring. It's basically like if you wear glasses, at the end of the day when you take your glasses off, it's kind of like, "Ah." It's hard work. You're training all day.

Marisha: Mm-hmm (affirmative). Yes, and especially in a classroom where there's so much going on.

Lauren DiBiase: Yeah.

Marisha: Oh my goodness.

Lauren DiBiase: Yeah, yeah. But it pays off for some. For some, it's really successful.

Marisha: Yeah, and can you give us a little bit of an idea? Because I'm super, super curious now, but what would that progression, just kind of like a quick snapshot of the progression? So we would start with just general noises, then move to the six sounds. Then once they start-

Lauren DiBiase: Right, and from the... Mm-hmm (affirmative). From the six sounds, you move to single words, and then you move to stereotypical utterances. Those are your utterances that are common phrases. Sit down. Stand up. Happy birthday. Bless you. I want more. Common short phrases like that. That's the next thing, because the child starts to learn the rising and lowering rhythm of those phrases and memorizes them that way. So there's also cards that you can use to match those utterances.

Lauren DiBiase: Then, of course, you want to take the cards away, because you want to start being more functional in real life. They're going to walk into your room, and you're going to tell them, "Sit down. Turn the lights off. Turn the lights on," things like that. So common, short phrases. After that, you're going to move onto single core vocabulary, common. Cat, dog, chair, apple, things that are common. Then you slowly, gradually move up to short phrases. Then once they seem to have that, you're going to start doing questions. Then it kind of becomes language based, like with what most people are familiar with, and asking and answering questions, comprehension of longer phrases, short stories, things of that nature.

Marisha: Yeah, so helpful.

Lauren DiBiase: Oh good.

Marisha: That makes a lot of sense. Then I know this varies a lot, but what's the fastest progression you've seen through that initial sound step to maybe, I don't know, whichever step you can think of? Can we expect that to take several years?

Lauren DiBiase: It can take-

Marisha: What do you typically see?

Lauren DiBiase: It really is... So most of the children that I've worked with have been deaf plus. What that means is that they're deaf and they have a disability, such as autism or cerebral palsy or a language disorder separate from the deafness. So if there is something additional that the child has, a diagnosis, it's going to take a lot longer. If the child is only deaf and there's no language delay and they haven't been deprived of language as an infant, they could move through it quickly.

Lauren DiBiase: The goal is for the child to make one year's progress in one year's time. Sometimes it happens. But it's super individual. Again, I know I keep saying it and I sound like a broken record, but a lot of it comes down to if the family's keeping up with the appointments and if the family has that equipment on all the time. A lot of times the kids don't want to wear it, so it's a struggle. It's not just the parents being negligent, or it's not a priority to them. A lot of times the kids put up a fight.

Marisha: Yeah. Yeah, that makes sense.

Lauren DiBiase: Yeah, so it can be quick. You're hoping for a year's progress in a year's time, but for some students, it takes a lot longer, especially if they're not receiving amplification until an older age, three, four, five. I see a lot of kids who come over from other countries. They come either without any equipment, or their equipment's been broken, or maybe it's super outdated equipment. They've now had a big time gap where they haven't had language exposure. Unfortunately, then they are starting kind of with an extra disadvantage.

Marisha: Yeah. That makes sense.

Lauren DiBiase: Yeah.

Marisha: Awesome. Then one more question about the two "paths". So if you are doing that dual approach, how do you structure that in the sessions? Do you do a mix of both within each session, or do you typically rotate it out, or do you go through phases?

Lauren DiBiase: Yeah.

Marisha: What does that look like when you're doing that?

Lauren DiBiase: So there's a couple of different approaches. You could do a schedule where there's a day for ASL and there's a day for auditory-verbal, and then a day for ASL. You never, never want to do both simultaneously. You literally don't want to be signing at the same time that you're speaking, because the syntax of the two languages is different. It's impossible. If I'm signing but I'm also speaking for some reason, one of those languages is suffering. Then what you have is a child who's not being exposed to the correct grammar of the language.

Lauren DiBiase: Let's say you're reading a book and there's a concept that you want the child to get in both languages. You're going to do a sandwich approach. So you might sign it voice off, and then speak it hands down, and the again voice off, sign it. Or you could do the opposite. You could speak it, hands down, then sign it, voice off, and then speak it one last time with hands down. So a lot of sandwiching, but I prefer to break it up solely by sessions, because for my own brain, it's easier that way, you know what I mean? It's just easier for me to separate for myself the two languages in that way, and that way I can just flick on my ASL brain or I can flick on my English brain, rather than going back and forth constantly.

Marisha: Yeah. I bet if it's confusing for us, then it's probably even more confusing for the student.

Lauren DiBiase: Definitely, yeah.

Marisha: Yeah, if we're feeling a little overwhelmed or confused, then I think that's a super good strategy.

Lauren DiBiase: Yeah, yeah. So that would be my best tip for working on that for bi-bi.

Marisha: Yeah. Okay, well, I've loved getting to talk about all of these topics, and I feel like I have... Like I said, I've dabbled a little bit, but it's been really helpful to get a little bit more of a walkthrough and kind of piecing all of the different pieces together. So thank you for that.

Lauren DiBiase: Oh, you're so welcome.

Marisha: Then I'm curious, do you have any last tips or things that we didn't get to talk about that you wanted to share or anything you just really want to emphasize?

Lauren DiBiase: I think what I would most want to emphasize, and I did say it before, but I would say it again, is to not be afraid of the unknown, to not be afraid of the equipment, to not be afraid to say to a parent or a teacher, "I don't know the answer to that. I don't know what to do, but I have the resources and I'm going to go find out, and we'll talk about this again in a week, in a day."

Lauren DiBiase: I think it's really important to tell yourself, "It's okay that I don't know everything." The speech and language field, it's astronomical. I don't know a single thing about voice, but I know where to go if I need to. So I think that's like the best thing about our field. It's huge and the FLPs in it are so eager and so willing to help each other out that it's okay to say, "I don't know what to do," or, "I'm going to..." You don't want to fake it until you make it in this instance, because every second with a kid with a hearing loss is crucial, because time is ticking. So you want to reach out to the resources that I spoke about on Facebook, and then you and I will go over the ones on my Instagram later. We can add those. But yeah, just to keep an open mind that maybe you're going to need to look outside of what you already know in order to best service this particular population.

Marisha: Yeah. I couldn't agree more. We really get to be problem solvers as speech language pathologists. We get to exercise that muscle regularly. This is a perfect opportunity to work on that. The good thing is that there are so many resources out there. We can totally figure it out and work together and provide awesome services for these students.

Lauren DiBiase: Definitely.

Marisha: Okay. Awesome. So to wrap up, where can listeners find out more about what you do and kind of get the resources that you were talking about?

Lauren DiBiase: So I love Instagram. I post just about every day and I show in real life what I'm doing in therapy. So my Instagram is slplaurendibiase. Then I also have a blog where I kind of share more in detail about the actual activities that I'm using. I have a lot of students who are doing life skills. My blog is www.slplaurendibiase.com. Then I am a teacher author, so I have my TPT store where I share a lot of resources for deaf, hard of hearing, but also my second passion is life skills, social skills. So my resources are mostly in that area. My store is my store name. So Lauren DiBiase.

Marisha: Amazing. Thank you so much for sharing. Then we will share all of these resources in the show notes too. So you can just go there and click all of the different links that we mentioned. That will be at slpnow.com/16. Yeah, thank you again, Lauren. This was so incredibly helpful.

Lauren DiBiase: Thank you so much for having me, Marisha. I really enjoyed being on the show.