Using Auditory Strategies in Purposeful
Play to Improve Communication
Virgi Mills, M.E.D.
MaryKay Therres, M.S., CCC-SLP, LSLS Cert. AVT
MED-EL Corp. USA
Disclosure
Virgi Mills, M.E.D.
Consumer Outreach Manager, Southeast Region
MaryKay Therres, M.S., CCC-SLP, LSLS Cert. AVT
Manager of Education and Therapy
• Virgi and MaryKay are both employees of MED-EL
Learning Objectives
 Participants will be able to list a progression of
auditory skills
 Participants will be able to list materials to assist in
monitoring progress and identifying goals
Purposeful Play
1. Identify age-appropriate toy/material
2. Identify child’s level of auditory skill,
expressive language skill and speech
production skill
3. Choose appropriate auditory, speech,
language and Theory of Mind goals.
4. For each goal, write out targets (scripts)
that facilitate the goal
5. Identify strategies to assist in development
of the goals
Play-why?
Contributes to:
 Physical development
 Social development
 Emotional development
 Cognitive/intellectual development
 Communication development
Fun
Types/Stages of Play
Piaget’s Stage Theory of Cognitive Development:
 Sensorimotor (birth to 2): build understanding through
interactions with the environment
 Preoperational (2 – 4 to 7): needs concrete physical
situations; does not conceptualize abstractly
 Concrete operations (7 – 11): begins to think
abstractly and conceptualize
 Formal operations (11+): capable of hypothetical and
deductive reasoning
Types/Stages of Play
Mildred Parton, 1933, looked at children between ages 2
– 5 and observed 6 types:
1. Unoccupied play: child is relatively stationary and
appears to be performing random movements without
purpose (infrequent)
2. Solitary play: child engrossed in playing and doesn’t
notice other children (most often seen between ages 0
– 2)
3. Onlooker/Spectator play: child takes interest in other
children’s play but doesn’t join in, primarily watches (2
– 2 ½ years)
Types/Stages of Play
4. Parallel play: child mimics other children’s play but
doesn’t actively engage with them (2 ½ - 3 years)
5. Associative play: shows more interest in others rather
than the toys; first category that involves strong social
interaction (3 – 4 years)
6. Cooperative play: organization enters the children’s
play (ie: play has a goal, rules, children act at group) (4
– 6 years)
Play Milestones
 Exploratory play from birth to 24 months
 Relational or functional play 9 – 24 months
(predominant 15 to 21 months)
 Begin to use some toys appropriately around 9 – 12
months
 Constructive play at 24 months but predominant 36
months +
 See more parallel play 2 ½ years to 3 years
 Interacting with peers begins around 2 ½ years
Play Milestones
 Cooperative play begins around 3 to 3 ½ years; begins
to share
 Rough and tumble play begins around 3 years and is
predominant from 4 – 5 years
 Enjoys play with simple concept and board games
(manipulatives) around 3 – 4 years
 Understands turn-taking and sharing around 3 – 4
years
 Play has a sequence of events around 3 – 4 years
 Prefer to play in small group emerges around 3 ½ - 4
years
Play Milestones






By 4 – 4 ½ years have good imaginative play
By 4 ½ - 5 years like working on projects (ie: cut/paste)
By 4 – 5 has good imaginative pretend play
Plays cooperatively with others by 4 – 5 years
By 5 – 6 years able to play games with rules
By 5 – 6 years more imaginative and plans many
sequences of pretend events (ie: going on a trip to
outer space)
Auditory Skills Pyramid
Level 4
Comprehension
Level 3
Identification
Level 2
Discrimination
Level 1
Detection
AuSpLan (Auditory Speech Language) A Manual for Professionals Working
with Children who have Cochlear Implants or Amplification
McClatchie and Therres 2003
Auditory Goals: Detection
 Awareness of Voicing
 Awareness of Environmental Sounds
 Awareness of Ling Sounds
Auditory Goals: Discrimination




Duration difference
Intensity difference
Pitch difference
Stress difference
Discrimination and beginning of attaching meaning
through familiar, routine utterances that differ by
suprasegmental
Auditory Goals: Identification
 Vocabulary development
 Auditory memory development
Increase number of key words, short to longer utterance,
closed to open set
Auditory Goals: Comprehension
Advanced vocabulary development including word-webs
Answer simple to complex questions
Understand more complex sentences
Listen to and understand paragraph(s) of information
Increase cognitive language skills: infer, interpret and
paraphrase, problem solve, identify missing information,
define and explain, predict, identify components in a
story, humor, figurative language
 Follow conversation with familiar topic
 Follow open-ended conversation





Language Levels
Level 6
Complex Sentences
Level 5
Expanded Sentences
Level 4
Simple Sentences
Level 3
Connected Utterances
Level 2
Word Production
Level 1
Word Approximation
Expressive Goals: Word Approximations
 Vocal intent
 Word approximations
Expressive Goals: Word Production
 Spontaneous production of first 5 to 10 words
 Spontaneous production of first 30 to 50 words
Expressive Goals: Connected
Utterances
 Imitation of 2 to 4 word utterance
 Spontaneous production of 2 to 4 word utterance
Expressive Goals: Simple Sentences
 Grammatical structure development-follow Brown’s
morphemes; sentence length usually 3 to 5 words
Expressive Goals: Expanded Sentences
 Interrogative sentence formulation
 Expanded sentence production with adjective, adverb
or prepositional phrase
Usually 5 to 8 words in length
Expressive Goals: Complex Sentences
 Conjoining sentence production
 Complex sentence production (embedded phrases,
passive sentence production)
 Discourse
Usually 6+ words in length
Hierarchy of Speech Intelligibility
Stage 6
Sentences
Stage 5
Phrases
Stage 4
Words
Stage 3
Sound Sequences
Stage 2
Isolation
Stage 1
Pre-Speech
Speech Goals: Pre-Speech
 Voice on/off
 Length imitation
Speech Goals: Isolation
 Vowel and consonant production in isolation
Speech Goals: Sound Sequences
 Facilitate speech babble (phonation to coo-goo to
expansion of vowels to canonical babbling to
variegated babbling)
 Remediate speech through apraxia approach: CV to CV
reduplicated to CVCV same C, different V to CVCV
different C, same V to CVCV different C, different V
Speech Goals: Words
 Imitated single words using sounds:_______________________
 Spontaneous single words using sounds:__________________
 Imitated single words without using phonological
process:___________________________________
 Spontaneous single words without using phonological
process:___________________________________
Speech Goals: Phrases
 Imitated 2 – 4 word phrases using sounds:________________
 Spontaneous 2 - 4 word phrases using sounds:__________
 Imitated 2 – 4 word phrases without using
phonological process:___________________________________
 Spontaneous 2 – 4 word phrases without using
phonological process:___________________________________
Speech Goals: Sentences
 Imitated sentences using sounds:________________
 Spontaneous sentences using sounds:_____________
 Imitated sentences without using phonological
process:___________________________________
 Spontaneous sentences without using phonological
process:___________________________________
 Spontaneous connected sentences
Theory of Mind (TofM)
Social Cognition
Information from Karen L. Anderson’s
website: successforkidswithhearingloss.com
Donna Sperandio, MED-EL Innsbruck
Joanna Brachmaier, MED-EL Innsbruck
Theory of Mind-definition
-the idea that each child develops an understanding of
their own thoughts, desires, beliefs, points of view,
motives, and can recognize that other people have these
which may or may not be the same as the child’s
What is Theory of Mind?
Two Key Terms
 ‘Mental state’ language
 ‘False belief’ understanding
What is Theory of Mind?
Mental State Language
 ‘Mental state’ words are not visible
 Words used about thoughts
False Belief Test
Is basic criterion for assessing TofM
1. A puppet named Max puts a chocolate in the
cupboard and leaves the room. The teacher/therapist
moves the chocolate to a new location and asks the
child where Max will look for it
2. Sally-Anne task: Sally and Anne put a marble in a box,
Sally leaves and Anne takes the marble out and puts it
in a different box
Up until about age 4, most children will ascribe their own
beliefs to Max and Sally and tell the teacher/therapist
that Max or Sally will look in the new location for the
chocolate or marble
www.education.com › School and Academics › Classroom
Learning building blocks of social cognition
TofM
Critical for:
reading comprehension,
socialization (peer
relationships) and success in school
TofM
Also important for:
-helping to communicate empathy, persuasion, inference,
reasoning, thinking critically and cooperation, and
understanding narratives and texts
-making conversations easier by predicting what the
listener already knows, how they are reacting, and
what should be said next
-reading comprehension (understanding characters in a
story)
TofM
Not generally taught directly
-learn by overhearing others use in
different contexts and situations
-learned incidentally
-learned as child is learning language
TofM Milestones
-by age 2: children can understand that people
will feel happy if they get what they want and
get sad if they do not
-2 year olds talk about what they and others
want and like and feel
-3 year olds also talk about what people think
and know
www.education.com › School and Academics › Classroom
Learning building blocks of social cognition
TofM Milestones
-by age 4: recognize that other people have
minds and that their minds may hold different
information; recognize that appearances may be
deceptive and can mislead
-by age 5: understand that someone who
appears happy may actually be sad
TofM Milestones
Ability to pass false-belief tests and appearancereality tests at about age 4 represent important
milestones in TofM development
Understanding false belief is universal in normal
children over the age of 5
Number of factors affect age at which skill is
acquired and language acquisition is one factor
TofM and Children with
Hearing Loss
 Even though they have good language skills, many
children with hearing loss lag several years behind
children with typical hearing in their ability to grasp the
beliefs of others
 There is a correlation between language level and
understanding false beliefs that is due to diminished
exposure to interactive conversations from a young
age
 Deaf and hard-of-hearing students are at risk for
delays in social cognition (Hands & Voices)
TofM and Children with
Hearing Loss
 To learn TofM, children need exposure to rich and
meaningful language and a range of opportunities to
hear this language across varying contexts
 Need access to this language and opportunities to
practice using it
 If has less exposure to TofM concepts then
development of these skills may be impacted
 For children with hearing loss exposure to language
alone might not be enough-need to understand the
language (inference, critical thinking) to learn from the
situation
Strategies for TofM
-Use
Mental State Verbs in everyday routines
think, believe, like, love, hate, imagine, hope,
remember, know, guess, feel, forget,
recognize, learn, perceive decide,
understand, miss, appreciate, surprise
ie: I don’t know where the cat is, I am
guessing he is hiding under the bed or he
could be outside.
Strategies for TofM
-Link
concrete objects with Mental State Verbs
-have a variety of objects and discuss why
you like one and not the others-then child
chooses one and explains why he likes that
one; then guess at which one parent may
like
Strategies for TofM
-Talk
about past experiences
-what happened earlier in the day, week while
using Mental State Verbs
-highlight perspectives, thoughts, motives of
others in those experiences
ie: Yesterday your brother wanted ice cream but
I felt that he had been feeling ill and ice cream
wouldn’t be good for him. I think tomorrow if
he is better he can have some.
Strategies for TofM
-Talk about upcoming/future events
-tell about future events giving reasons why you
participate and ask questions to include child
in conversation
ie: I would like to go the zoo on Saturday. I like
seeing the animals. I think the monkeys may
be swinging in the trees. Do you remember
when we went to the zoo a few months ago? I
forget if we saw the elephants last time.
Strategies for TofM
-Name
the Mental States as they happen
-draw the child’s attention to other’s mental
states as they happen such as when someone
is thinking point out they are thinking but we
don’t know what they are thinking; someone is
smiling so they are feeling happy
ie: Mom is thinking about what to make for
dinner. Let’s guess at what she will make.
Strategies for TofM
-Pretend play (act out scenarios with dolls)
-Read books (think about characters, how
they feel, infer, think about choices or what
to do next, books with surprise, tricks)
-Play Hide and Seek (guess)
-Tell Make-Believe Stories (pretend)
-Explain Why People Behave the Way They Doemotions (how someone’s actions can
affect the people around them-hurt
feelings)
Social Skills Ideas
Pediatrics
Center on Social Emotional Foundations
in Early Learning
http://csefel.vanderbilt.edu/
Tucker Turtle
Takes Time to
Tuck and
Think
A scripted story to assist with
teaching the “Turtle Technique”
By Rochelle Lentini, University of South Florida
Updated 2007
Created using pictures from Microsoft Clipart® and Webster-Stratton, C. (1991). The teachers and children videotape series: Dina dinosaur
school. Seattle, WA: The Incredible Years.
When Tucker got mad, he used to hit, kick, or
yell at his friends. His friends would get mad or
upset when he hit, kicked, or yelled at them.
Tucker now knows a new way to “think
like a turtle” when he gets mad.
Step 1
He can stop and keep his hands, body,
and yelling to himself!
Step 2
He can tuck inside his shell and take 3
deep breaths to calm down.
Step 3
Pediatrics
Solution Kit
Pediatrics
Feelings
Pediatrics
Oh Mr. Sun, Sun
Mr. golden Sun,
Won’t you smile
down on my friend,
Mary!
Pediatrics
Figurative Language and Idioms
Meredith Ouellette, MS
Director of Clinical Services
The River School, Washington, DC
Pediatrics
Auditory Verbal Therapy
Strategies
1. On all waking hours: child wears hearing
aids/cochlear implant whenever awake.
2. Come close to me: when speaking to the child be
close so has better access to sound.
3. Talk more: use language with child all the time-talk
about what you are doing, talk about what the child is
doing, talk about what you see around you.
4. Auditory hooks: use words/phrases that have the
sing-song voice with them to grab child’s attention
and start to develop understanding of the language
that goes with the object/action; use familiar
vocabulary in routine situations.
5. Thinking place: joint attention, you and the child are
focuses on the same thing.
6. Acoustic highlighting: a sound or a sound in a word,
word or phrase is slightly emphasized (highlighted) to
draw child’s attention to it. Can be used in any spoken
language throughout the world.
7. Auditory sandwich: gives the child
three chances to listen:
1.
listen alone, 2. listen with support,
3.
listen alone. Supports can include
point/gesture, show a picture/toy/object, speech read or
sign.
8. Check for comprehension: ask child specific questions
about information presented.
9. Ask what they heard: have child repeat. Particularly
useful when checking auditory memory or auditory
discrimination.
10. Parent (or other) as a model: to provide appropriate
response for child; after modeled then child is given
chance to respond.
11. Repetition: use if child does not understand or
misses part of something. DO NOT OVERUSE.
12. Rephrase: say it a different way or at a simpler level.
13. Pause/wait time: pausing and waiting with
anticipation encourages a child to listen and follow
through with a task rather than waiting for
the speaker to repeat.
Some children require
longer auditory processing
time. Also used when
encouraging a child to
spontaneously verbalize.
14. Expand: response to child in which word order is the
same and utterance is made longer and/or grammatically
correct. Recast into adult syntactic form.
15. Extend: respond to child’s utterance in
conversational way, providing a bit of new information
that is related to what the child had to say.
16. Clarification: skill to teach child; child learns to selfadvocate when breakdowns in communication occur;
requests specific information rather than “I didn’t hear
you”, “say it again”.
17. Sabotage: two ways
- adult creates a problem or makes a mistake to block a
goal of the child, thereby creating a context in which
the child needs to communicate if he/she wants to
overcome the difficulty and proceed with the activity
- adult makes a mistake to give child opportunity to
identify and correct the mistake
18: Listening first: present with audition first and then if
needed add visual cues to help understanding.
19. Favorable listening environment: keep the noise level
down.
20. Auditory feedback loop: have child listen then repeat,
works on the auditory system (listen-process-repeat).
21. My voice matters: acknowledge and encourage child
to use voice and later words to communicate.
22. Choices: Provide child with choices for understanding
and to also communicate to you what they want.
23. Build auditory memory: important for language
development.
24. Music: expose to-sing.
25. Books: expose to-important for literacy development.
Strategies for all levels of auditory













On all waking hours
Come close to me
Talk more
Expansion/extension
Thinking place
Listening first
Signal to noise ratio
Pause-wait
Auditory feedback loop
My voice matters
Music
Books
Parent as model
Four Levels of Auditory Skills




DETECTION: “can you hear this?”
DISCRIMINATION: “does this sound different from that?”
IDENTIFICATION: “what did you hear?”
COMPREHENSION: “what does it mean?”
 Adapted from: Erber, N. (1982). Auditory Training. Washington DC:
Alexander Graham Bell Association, pp. 92-94.
Detection
Response:
 Repeatedly shows awareness of
sound/speech. Individual can detects sounds
but will not understand what they mean.
Will know that a sound is present.
Strategies for Detection
Wear the cochlear implant all day, everyday
Check detection of the 6 Ling sounds daily
Prepare listener by saying “Listen”
Point to your ear and comment “I hear that” or “You
heard that”
 Repeat the sound




Discrimination
Response:
 Indicate similarity or difference (same/not same).
Individual can recognizes that there’s a differences
between sounds and words through listening. This is
done through recognizing and possibly imitating the
differences or showing beginning understanding in
words/phrases that differ in duration, pitch,
intonation, length, and/or rhythm.
 Use auditory hooks-words/phrases to get the child’s
attention. These are used with much sing-song
voice.
Strategies for Discrimination








Prepare listener by saying, “Listen.”
Contextualize the information-make it meaningful.
Use the auditory sandwich.
Repeat.
Use greater acoustic contrasts.
Auditory hooks
Acoustic highlighting
Use choices
Identification
Response:
 Point to item named by speaker, repeat
stimulus. Individual is building a listening
vocabulary and understands simple words,
phrases and, sentences along with
sequential memory for sequences of words.
Strategies for Identification













Vocabulary Development
Auditory Memory
Prepare listener by saying, “Listen,” or “Ready?”
Contextualize the information-make it meaningful.
Use the auditory sandwich.
Repeat the information.
Change the position of the key word in the sentence.
Change the number of items to recall.
Acoustic highlighting
Rephrase
Auditory sandwich
Sabotage
Use choices
Comprehension
Response:
 Individual can understand longer and more
complex spoken language; can answer
questions; uses thinking skills like inference;
and engage in a conversations with different
people in a variety of settings.
Strategies for Comprehension













Know what is developmentally appropriate.
Prepare listener by saying, “Listen,” or “Ready?”
Contextualize the information-make it meaningful.
Use the auditory sandwich.
Repeat the information.
Acoustic highlighting
Auditory sandwich
Sabotage
Use choices
Rephrase
Chunk important phrases together.
Reword or summarize the information the second time.
Ask specific questions to encourage thinking.
Reviewed
-Play Milestones
-Auditory Hierarchy
-Expressive Language Hierarchy
-Speech Production Hierarchy
-Theory of Mind
-Strategies
Now put into Purposeful Play
Auditory: Comprehension
Auditory Targets:
Goal: Infer from information provided.
Targets:
The little boy is hungry what should he do?
What is something that has wheels and windows and you
drive it?
What is something that that goes on your bed and you
use it when you are cold?
Mom wants to go to the store to buy groceries, how
should she get there?
Language: Expanded
Sentences
Expressive Targets:
Goal: Produce 5 to 8 word sentences containing an
adverb, adjective or prepositional phrase.
Targets:
Robin is standing on the balcony.
Batman is riding on his motorcycle.
Batman is flying very fast.
Robin is hiding in the cave.
Robin is riding on the black motorcycle.
Batman is behind the purple bars.
Speech: Phrases
Speech Targets:
Goal: Produce 2 to 4 word phrases with 80% intelligibility
using beginning sounds: /b, m, p, w, n, d, t/.
Targets:
Weeble up
Weeble go down
Open the door
Put weeble in
Take weeble out
One more time
Ready, set, go
Go more
In the tree
On the tree
My turn
Daddy Weeble
Two Weebles
Time to go
Bye bye weeble
Theory of Mind/Social
Cognition
TofM Targets:
Goal 1: Discuss other’s feelings
Goal 2: Role play
Goal 3: Vocabulary exposure think, feel, remember
Targets:
Discuss feelings: The gorilla is swinging by himself, maybe he
feels lonely.
Role play: I’m the zoo keeper and I am going to go feed the
animals. Mr. Lion I will be careful by you because you are
mean. Why is he mean? Mr. Bear, I will be quiet by you
because you are sleeping and I don’t want to wake you up.
How would the bear feel if I woke him up?
Vocabulary: How do you think the lion would feel if he fell in
the water? Why does the gorilla feel lonely? Do remember if
you ever went to the zoo and if so, what did you think
about it?
Integrated Goals
• Auditory Goal and Targets
• Expressive Language Goal and Targets
• Speech/Articulation Goal and Targets
• Theory of Mind/Social Cognition Goal and Targets
Integrated Goals
Auditory Goal: Sequence 3 to 4 part story.
Targets: Flynn is riding his horse to the tower. He gets off his
horse and picks up the frog. Then he climbs up the hair and
gives the frog to the girl.
Language Goal: Use simple sentences with present
progressive ing.
Targets: The girl is sitting. The frog is hopping. The horse is
running. Flynn is climbing up.
Speech Goal: Produce /f/ blends.
Targets: Flynn is riding the horse. The frog is hopping. The
flowers are pretty. The bird is flying around. The girl is
flinging her hair down.
TofM Goal: Discuss misunderstandings-how things could be
perceived.
Target: Discuss that the girl is in the tower and does not have
friends. People have misunderstood why-thought she was
shy/did not want to be friends with others-snobbish. Real
reason is she was stuck in the tower so people thought she
was a different personality than she really is.
Time to Play
• Participants will be divided into groups and provided
with a toy and case study
• Each group will identify the level of the child’s auditory,
expressive language and speech skills and then
determine an appropriate goal for each
• Each group will also determine a Theory of Mind goal
• Using the toy provided, each group with then write out
a few targets/scripts to help facilitate the goal
www.medel.com