Teens Through an AVT Lens

Adolescence Through the Lens of an Auditory-Verbal Therapist with Hearing Differences

By Ellen A. Rhoades, Ed.S., LSLS Cert. AVT

I was born with bilateral 85 dB hearing loss and wore a high-powered unilateral hearing aid since 2 years of age, way back in 1947. Having developed effective listening and spoken language skills, I was a functionally hearing student and was mainstreamed in the first grade. I eventually became an elementary school teacher and realized that I had a passion for working with children and adolescents who also had hearing differences like me. When I took my first audiology course in graduate school, I learned that I was audiometrically deaf. Since then, I have been keenly interested in psychosocial issues associated with hearing loss. Immediately after obtaining my master's degree in 1972, I began providing auditory-verbal therapy (AVT) and was among the first practitioners recruited by Helen Beebe, Ciwa Griffiths and Doreen Pollack to organize the discipline then known as AVT in 1977. When the certification process was established, I naturally became certified as an auditory-verbal therapist. In 1993, I received a cochlear implant after losing some of my residual hearing. Since then, I have established several auditory-verbal programs and authored professional articles and books.

When I work with and counsel youth with hearing loss and their parents, I immediately begin to elevate expectation levels and move to reframe labeling issues associated with stigma, stereotypes and self-fulfilling prophecies which are documented in the evidence-based literature (Rhoades, 2010). I also work to identify each child's positive dispositional traits which are among the personal resources necessary for good psychosocial and physical health as well as effective learning (Froh, Huebner, Youssef, & Conte, 2011). Both are complex psychosocial issues integral to the framework for my auditory-verbal intervention with students of all ages.

Realistic Optimism and Reframing Circumstances

An important dispositional trait that enables children and adolescents to thrive is that of realistic optimism. We know that a positive outlook influences how we interact with others (Lount, 2010). Optimism, associated with positive thinking, also has to do with favorable expectancies for the future (Carver & Scheier, 2014). This dispositional trait can be learned (Peters et al., 2010). Therefore, repeatedly promoting a sense of optimism is one of my goal-based issues across therapy sessions.

The ability to reframe any situation or event in a positive light is essential to optimism (Alter et al., 2010). Giving youth with hearing loss opportunities to engage in the reframing process can be relatively simple by showering them with optimistic proverbs and metaphorical expressions (Pierro et al., 2012). Examples include:

  • Every cloud has a silver lining.
  • My glass is half full, not half empty.
  • There are two sides to every coin.
  • Living on earth may be expensive, but it includes a trip around the sun each year.

When I hear adults with typical hearing make pessimistic statements, I am cheerfully reminded that my father did the right thing by persistently changing my outlook on the dilemmas of life.  


I often play a game  with students called Fortunately-Unfortunately. Either the practitioner and student or two students can play, taking turns with each other. One is designated to be the optimist and the other person is the pessimist. One person makes a statement that reflects either a positive or negative viewpoint, depending on their designated disposition. Alternating turns, each statement made should continue in a somewhat similar thread so that a story develops.

For example, person A (the designated optimist) says, “Fortunately, the bed is comfortable.” Then, person B (the designated pessimist) says, “Unfortunately, the bed was very small.” Person A continues: “Fortunately, the bed had side bars so I did not fall off.” Person B chimes in: “The side bars were smelly.” And so on.

The Importance of Traveling Well

There is something that can be learned from each difficult situation or event experienced by students. I have a list of adverse situations that I present to students, challenging them to find one positive aspect that can be extracted from each situation. Along with practicing the art of reframing, youth with hearing loss can learn that failure is instructive and that for every limitation a strength can be perceived or something can be learned. Failing well can stand us well.

Although the importance of having conversations about pain, adversity and mistakes cannot be underestimated, it is equally important to generate vivid positive mental imagery of the future; this helps youth with hearing loss focus on goals and problem solving (Blackwell et al., 2013). As a practitioner, I try to praise students' efforts more than their outcomes or achievements (Young et al., 2008). To promote positive dispositional traits, praise the process rather than the product.

In helping students become strength-based, I engage them in written or verbal activities whereby they complete these statements: I have ___. I am ___. I can ___. I also give each student a copy of “Ten Rules For My Well Being” (Figure 1).  Over time, we discuss each rule and my goal is to have them understand and buy into those rules. Rather than blaming others for our problems, we work to normalize adversities and accept them as part of life. This means we see dilemmas as typical experiences that help us grow and become more confident. A “can do” spirit is promoted when we place youth with hearing loss in situations whereby they must persevere to learn new skills. As children mature, they become increasingly flexible by embracing the “new normal.”

Exploring and Constructing a Fluid Self-Identity

Self-affirmation activities encourage youth with hearing loss to engage in self-reflection (Stinson et  al., 2011). This means thinking about those values they deem important, and explaining why those values are relevant to them (Kaplan & Flum, 2012).

Examples of probing questions that can elicit thoughtful responses and promote self-awareness include:

  • Why is this belief important to you?
  • Of all your values, which one is most important to you?
  • What does it mean to be...?
  • How do you feel about these labels: hearing impaired, hard of hearing, deaf, hearing disabled, atypical hearing?

I take great care to convey to students that I respect all viewpoints in a confidential, safe and non-judgmental way (Renshawa, Choob, & emerald, 2014).

Figure 1.  Ten rules for my well-being*

  1. I belong.
  2. I am unique and that is good.
  3. I can change my brain; I can and will construct my own reality.
  4. I recognize my own strengths and weaknesses.
  5. I sometimes request help, but always take responsibility for my successes and failures.
  6. I believe that failure is instructive, so I will learn from my mistakes.
  7. I will be persistently optimistic, even in the face of adversity.
  8. I do and always will try to laugh at myself.
  9. I must continue being receptive to new ideas.
  10. I understand that anything is possible, so I create my own future.

*Rhoades, E.A. (2003). Ten rules for my well-being. Auditory-verbal intervention for adolescents workshop. Minneapolis, MN.  

In spite of congenital deafness and my personal experiences, I make a concerted effort to avoid viewing each student through that same lens. Although hearing status may not be the primary definer for either me or some students with hearing differences, it may be so for other students (Punch & Hyde, 2011). Sometimes, hearing status is viewed as a deficit-based facet of one's identity. This type of discussion lends itself well to alternative ways we might solve problems such as remedying those situations where understanding others is difficult.    

Because identities are fluid and evolving as we mature, it is critical to understand the multidimensionality of who we are (Sinai, Kaplan, & Flum, 2012). The exploration and construction of self-identity is a topic worthy of discussion with all adolescents (Kaplan & Flum, 2012). Each one of us is a product of our respective families, parental attitudes and ethnic heritages as well as socioeconomic conditions, and all young children can benefit from learning about such diversity (Ramsey, 2008). For many adolescents, the language used at home or the student's physical appearance is of greater importance than their hearing differences, particularly when those facets deviate from the norm of the majority culture (Erb & Gebert, 2014).

At any rate, among all students, cultural explorations tend to foster greater understanding and appreciation of differences (Schwartz, Kurtines, & Montgomery, 2005). Each adolescent tends to view the self in terms of multiple or nested selves that are renegotiated, depending on circumstances (Crawford, 2007). One enjoyable and interesting activity for me and the students is visually showing our nested identities on paper, and the relative importance that we ascribe to each facet; this project can result in creative images.

I encourage students to share their inner stories—how they feel before, during and after challenging situations. Exploratory vehicles include reading and telling identity-related stories or poems, writing essays, developing goals and potential solutions to problematic situations, having small group discussions, participating in group projects, role-playing conflicts, creating puppet shows, attending cultural events, controlling specific impulses, and engaging in formal mock debates.     

Fitting in and Staying True to Self

Adolescents with hearing differences, just like adolescents with typical hearing, are complex individuals reflecting great heterogeneity (Leigh et al., 2009). Unfortunately, some adolescents do not feel socially connected to their peers (Pijl & Frostad, 2010). Group affiliation and acceptance is a fundamental human need. Adolescents who experience social rejection may feel dehumanized (Bastian & Haslam, 2010). Those who don't “fit in” may be distrusted, stereotyped and homogenized (Ellemers, 2012). We tend to like those who are similar to us, who look and sound and think like us. So I urge students feeling excluded to take the extra step in kindness. Toward that end, we either discuss or reenact interpersonal situations (see Figure 2 for a sample of such situations).

Figure 2. Sample of interpersonal situations 

  • offering help to another
  • hosting a social gathering
  • resolving a physical fight without being aggressive
  • assisting someone who erred
  • teaching someone how to improve certain skills
  • giving and accepting feedback
  • making discrete, direct, tactful comments
  • engaging taciturn others in conversation
  • effectively leading a group to complete a project
  • serving as motivational team leader in a sport
  • engaging in a debate
  • facilitating a brainstorming session in a group
  • enhancing cohesion from multicultural group of peers
  • serving as peer mediator on verbal level
  • making small talk that elicits conversation from others
  • effectively changing a topic
  • joining in on a conversation
  • asking for help

Because disengaged students are at great risk for poor developmental outcomes (Cruwys et al., 2013), I make a concerted effort to collaborate with parents and other established service providers so as to meet each adolescent's needs. Efforts are made to find an acceptable group for each student, and this can involve after-school leisure activities such as team sports, civic clubs and art classes as well as programs such as AG Bell’s Leadership Opportunities for Teens (LOFT) and AG Bell chapter activities. Positive social interactions can mitigate previous negative attitudes (Hergenrather & Rhodes, 2007).

With at-risk students, I focus on their unique and positive attributes so they can realize they are valued. At the same time, I embark on the quest of improving their goal-directed problem solving skills as well as their prosocial skills, which are behaviors that benefit other people or society as a whole. More often than not, isolated students have insufficient communication skills (Stevenson et al., 2010). The nature and extent of my therapy sessions changes with those students who lack that sense of belonging so crucial to identity construction and healthy self-esteem.

Developing Prosocial Skills: Theory of Mind

On the face of it, promoting prosocial skills may seem rather simple in that we just need to teach students how to share and use the niceties of spoken language (Brownell, 2013). But it is a bit more complicated than that. There are ample data demonstrating that some adolescents with hearing differences, relative to their peers with typical hearing, have not developed sufficient Theory of Mind (e.g., Schorr, 2006). This means that some youth with hearing loss need to be taught how to attribute mental states to oneself and to understand that others have beliefs, desires and intentions that are different from their own. This construct, Theory of Mind (Frith & Frith, 2006), may also be referred to as mentalizing (Blakemore et al., 2007), cultural intelligence (Hermann et al., 2007), socio-emotional intelligence (Goleman, 2006) or social cognition (Striano & Reid, 2009).

The Four Social Cognitive Skills

At the least, there are four important social cognitive skills underlying effective prosocial skills. Two of them are typically learned before or during the elementary grades: perspective-taking and empathy. However, counterfactual thinking and sarcasm perception are typically not well learned until adolescence; these later-developing social cognitive skills are heavily vested in communicative competency.

For my at-risk students, I recommend a full neuropsychological evaluation. However, considerable time may lapse between my recommendation and receiving the psychologist's report. So, in order to know in which direction my therapy sessions should quickly go, I first ascertain whether the student has a sufficient “mentalistic lexicon” (see Figure 3 for a sample of such vocabulary). Understanding words that describe how people feel and think is needed for social inclusion (Morgan et al., 2014). 

Figure 3.  Sample of a mentalistic lexicon





I also quickly determine whether my at-risk students understand perspective-taking on emotional and cognitive levels. A picture book that I often use refers to the classic Hindu fable about six blind men and an elephant. Can the student coherently relate to me why and how each blind man views the elephant in a different light? Then, using sequence pictures of faceless characters, I ask questions about how each character might have felt. Does the student understand that different people can have different perspectives about the same situation? Does the adolescent know what it means when people feel conflicted in certain situations? I also encourage students to take opposite positions in varied problematic situations as well as across racial and socioeconomic conditions (Gillespie & Richardson, 2011).

Based on my brief evaluation, we may work toward improving the student's mental state talk (mentalistic lexicon) as well as facilitating a sense of empathy. As needed, I use hearing differences as a means of sensitizing students to negative feelings. Any experiences that students may have had with social rejection can help them better understand others (Seery, 2011). To facilitate their perspective-taking skills, I provide adolescents with multiple activities in multiple contexts. During this ongoing process, we work on understanding social blunders. We also practice the art of anticipation and prediction—figuring out how people will behave based on what we have learned about their feelings.

Counterfactual Thinking
When these skills are in place, my therapeutic focus shifts to promoting counterfactual thinking. This involves considering how a past event could have been better or worse (i.e., what might have been). The linguistic pattern typically used in developing this skill is “If..., then...” which can involve blame and responsibility. For example, “If he does not do his homework, then he may fail the course.” Initially developed across the childhood years, counterfactual thinking is associated with causal reasoning (Beck & Riggs, 2014). When engaged in problem solving, adolescents are encouraged to think about how outcomes could be different (counterfactual alternatives).

Figurative Language
Subsequent to this, I'll use much figurative language, particularly engaging students in the art of sarcasm and irony (this can include painless teasing). Making snarky comments is a hallmark of adolescent communication and social cognition. While developing their knowledge of non-literal language (metaphors, similes, puns, idioms, analogies), we also learn about such paralinguistic cues as facial expressions and tone of voice in order to broaden their understanding of sarcasm (Nicholson et al., 2013). To facilitate ease with linguistic ambiguity, we share jokes, riddles and proverbs (Duncan, Rhoades, & Fitzpatrick, 2014).

The ultimate goal is to enable youth with hearing loss to become capable of attaining positive outcomes. Irrespective of hearing differences, youth should be able to thrive despite the many challenges they encounter in life. They should independently undertake important responsibilities and feel motivated with a sense of belonging and appropriate future-focused mindset. Each person should become an effective goal-directed problem solver with strong self-awareness, healthy self-esteem and a positive outlook on life.

Alter, A. L., Aronson, J., Darley, J. M., Rodriguez, C., & Ruble, D. N. (2010). Rising to the threat: Reducing stereotype threat by reframing the threat as a challenge. Journal of Experimental Social Psychology, 46, 166-171.

Bastian, B., & Haslam, N. (2010). Excluded from humanity: The dehumanizing effects of social ostracism. Journal of Experimental Social Psychology, 46, 107-113.

Beck, S. R., & Riggs, K. J. (2014). Developing thoughts about what might have been. Child Development Perspectives, 8, 175-179.

Blackwell, S. E., Rius-Ottenheim, N., Schulte-van Maaren, Y. W., Carlier, I. V., Middlekoop, V. D., Zitman, F. G., … Giltay, E. J. (2013). Optimism and mental imagery: a possible cognitive marker to promote well-being. Psychiatry Research, 206, 56-61.

Blakemore, S., den Ouden, H., Choudhury, S., & Frith, C. (2007). Adolescent development of the neural circuitry for thinking about intentions. Social Cognitive & Affective Neuroscience, 2, 130-139.

Brownell, C. A. (2013). Early development of prosocial behavior: Current perspectives. Infancy, 18, 1-9.

Carver, C. S., & Scheier, M. F. (2014). Dispositional optimism. Trends in Cognitive Science, 18, 293-299.

Cruwys, T., South, E. I., Greenaway, K. H., & Haslam, S. A. (2014). Social identity reduces depression by fostering positive attributions. Social Psychological and Personality Science, 5 (in press).

Duncan, J., Rhoades, E. A., & Fitzpatrick, E. M. (2014). Auditory (re)habilitation for adolescents with hearing loss. New York, NY: Oxford University Press.

Ellemers, N. (2012). The group self. Science, 336, 848.

Erb, H-P., & Gebert, S. (2014). Uniquely you. Scientific American Mind, 25, 26-33.

Frith, C. D., & Frith, U. (2006). The neural basis of mentalizing. Neuron, 50, 531-534.

Froh, J. J., Huebner, E. S., Youssef, A-J., & Conte, V. (2011). Acknowledging and appreciating the full spectrum of the human condition: School psychology's limited focus on positive psychological functioning. Psychology in the Schools, 48, 110-123.

Gillespie, A., & Richardson, B. (2011). Exchanging social positions: Enhancing perspective taking within a cooperative problem solving task. European Journal of Social Psychology, 41, 608-616.

Goleman, D. (2006). Social intelligence: The new science of human relationships. New York, NY: Bantam Books.

Hergenrather, K., & Rhodes, S. (2007). Exploring undergraduate student attitudes toward persons with disabilities: Application of the disability social relationship scale. Rehabilitation Counseling Bulletin, 50, 66-75.

Hermann, E., Call, J., Hernàndez-Lloreda, M. V., Hare, B., & Tomasello, M. (2007). Humans have evolved specialized skills of social cognition: The cultural intelligence hypothesis. Science, 317, 1360-1366.

Kaplan, A., & Flum, H. (2012). Identity formation in educational settings: A critical focus for education in the 21st century. Contemporary Educational Psychology, 37, 171-175.

Leigh, I. W., Maxwell-McCaw, D., Bat-Chava, Y., & Christiansen, J. B. (2009). Correlates of psychosocial adjustment in deaf adolescents with and without cochlear implants: A preliminary investigation. Journal of Deaf Studies and Deaf Education, 14, 244-259.

Lount, R. B. (2010). The impact of positive mood on trust in interpersonal and intergroup interactions. Journal of Personality and Social Psychology, 98, 420-433.

Morgan, G., Meristo, M., Mann, W., Hjelmquist, E., Surian, L., & Siegal, M. (2014). Mental state language and quality of conversational experience in deaf and hearing children. Cognitive Development, 29, 41-49.

Nicholson, A., Whalen, J. M., & Pexman, P. M. (2013). Children's processing of emotion in ironic language. Frontiers in Psychology, 4, 691.

Peters, M. L., Flink, I. K., Boersma, K., & Linton, S. J. (2010). Manipulating optimism: Can imagining a best possible self be used to increase positive future expectances? The Journal of Positive Psychology, 5, 204-211.

Pierro, A., Mannetti, L., Kruglanski, A. W., Klein, K., & Orehek, E. (2012). Persistence of attitude change and attitude-behavior correspondence based on extensive processing of source information. European Journal of Social Psychology, 42, 103-111.

Pijl, S. J., & Frostad, P. (2010). Peer acceptance and self-concept of students with disabilities in regular education. European Journal of Special Needs Education, 25, 93-105.

Punch, R., & Hyde, M. (2011). Social participation of children and adolescents with cochlear implants: A qualitative analysis of parent, teacher, and child interviews. Journal of Deaf Studies and Deaf Education, 16, 474-493.

Ramsey, P. G. (2008). Children's responses to differences. NHSA Dialog, 11, 225-237.

Renshawa, P., Choob, J., & emerald, e. (2014). Diverse disability identities: The accomplishment of 'Child with a disability' in everyday interaction between parents and teachers. International Journal of Educational Research, 63, 47-58.

Rhoades, E. A. (2010). Revisiting labels: 'Hearing' or not? The Volta Review, 110(1), 55-67.

Schorr, E. A. (2006). Early cochlear implant experience and emotional functioning during childhood: Loneliness in middle and late childhood. The Volta Review, 106(3), 365-379.

Schwartz, S. J., Kurtines, W. M., & Montgomery, M. J. (2005). A comparison of two approaches for facilitating identity exploration processes in emerging adults: An exploratory study. Journal of Adolescent Research, 20, 309-345.

Seery, M. D. (2011). Resilience: A silver lining to experiencing adverse life events? Current Directions in Psychological Science, 20, 390-394.

Sinai, M., Kaplan, A., & Flum, H. (2012). Promoting identity exploration within the school curriculum: A design-based study in a junior high literature lesson in Israel. Contemporary Educational Psychology, 37, 195-205.

Striano, T., & Reid, V., Eds. (2009). Social cognition: Development, neuroscience and autism. West Sussex, United Kingdom: Wiley-Blackwell.

Stevenson, J., McCann, D., Watkin, P., Worsfold, S., Kennedy, C., & Hearing Outcomes Study Team (2010). The relationship between language development and behaviour problems in children with hearing loss. Journal of Child Psychology and Psychiatry, 51, 77-83.

Stinson, D. A., Logel, C., Shepherd, S., & Zanna, M. P. (2011). Rewriting the self-fulfilling prophecy of social rejection: Self-affirmation improves relational security and  social behavior up to two months later. Psychological Science, 22, 1145-1149.

Young, A., Green, L., & Rogers, K. (2008). Resilience and deaf children: a literature review. Deafness and Education International, 10, 40-55.

Source: Volta Voices, November/December 2014