Auditory Dominance

In September 2019, I sat with Zahra, one of India’s most widely known practitioners of auditory verbal therapy, in her large and airy clinic space surrounded by gardens in central Mumbai, swatting at mosquitos as we chatted. Zahra is universally respected in India and held up as an example of a top-notch AVT specialist; many surgeons, audiologists, and speech and language pathologists commented on her excellent listening and spoken language outcomes with deaf children. Zahra cannot, however, officially call herself an auditory verbal therapist because she has refused to become certified by the Alexander Graham Bell Academy, the international AVT certifying body based in the United States. I asked Zahra why she had not sought certification and she scoffed, insisting that she did not need a piece of paper to prove her worth as a therapist. Indeed, she had been a practicing therapist long before the certification came into being. Zahra first learned about AVT more than thirty years ago from a visiting Australian AVT practitioner, one of the many “experts” who traveled to India to teach different re/habilitation methods. At that time, before cochlear implants had become widely available, she had been working with a small group of children out of her house, and she did not know if the method would work. All she knew was that she wanted to teach deaf children to listen and speak.

One day, Zahra was in the middle of a lesson with a child. A friend stopped by to visit, and she turned her attention to her friend. However, the child kept talking, even though Zahra’s friend was also talking. Zahra asked the child to stop talking in deference to her friend. The child replied: “No, you stop talking. I was talking first.” Zahra knew at that moment that AVT was working for this child because she was appropriately social. The girl knew how to take turns, and she responded confidently and independently (although her sassy comeback might not be universally appreciated). For Zahra, “success” was not only about developing a child’s ability to utilize listening and spoken language but also about developing a social sense—which for her and other AVT practitioners hinged on the development of a sensorium in which audition is the dominant sense. Audition first, and then everything else will follow. “Everything else” means interacting through listening and spoken language, engaging in dyadic turn-taking, and maintaining a contextually sensible conversation through speech. The goal is to inhabit the world in a way that is effortlessly and normatively intelligible to others.

AVT is a set of principles and a methodology focused on maximizing deaf children’s ability to relate to the world through audition. It entails ensuring appropriate auditory technology (often called sensory aids) such as hearing aids and cochlear implants, minimizing visual cues, modeling “natural” and “social” turn-taking and conversation, and maximizing parental involvement. Therapists stress that children and families must start AVT as early as possible, ideally before the age of three, with increased age correlating with decreased outcomes, although different therapists have varying perspectives on who is “too late” or “too old” (or “too disabled,” with other disabilities besides deafness affecting outcomes). AVT is not speech therapy in that it focuses on maximizing a child’s ability to use audition and not on speech per se; listening is emphasized before speech, a point that AVT practitioners stress constantly.

I attend to the development and proliferation of AVT as a specific therapeutic method with great purchase in cochlear implant infrastructures; I interrogate what kind of sensing subject AVT aims to produce as well as the linguistic, semiotic, and sensory ideologies with which it is bundled. Historically and currently, speech and language therapists, audiologists, families, and manufacturers of hearing aids and cochlear implants have argued that AVT is successful in creating “auditorily dependent” and “wonderfully verbal” children, as evidenced in the quotation from Dr. Rashmi above. In AVT circles, a hierarchy of sensing exists: value is placed on having an auditory brain, being an auditory person, and minimizing visual language and communication; the ultimate goal is sensory normativity.

Again, AVT is not speech therapy: speech therapy often invokes strongly negative feelings in sign language–speaking deaf adults (and in AVT practitioners as well). In the realm of deafness, anthropologists, neuroscientists, and other scholars have criticized speech therapy’s failure to produce adequate language development and socialization and have pointed to the continuing dominance of such therapy as evidence of oralist (valuing spoken language) ideologies.1 Unlike speech therapy, AVT is seen as unleashing and cultivating potential through its work on the brain and the senses (although, as with speech therapy, there is always the risk of failure).

Cochlear implants provide new opportunities for producing ideal sensory subjects and sensory infrastructures predicated on listening and spoken language. AVT principles and methods are key to this production, and one cannot discuss cochlear implant outcomes without also talking about AVT’s role in these outcomes. AVT has brought into being new conceptions of the senses, the body, and language: it depends on the division of the senses into discrete entities and the creation of communication, modality, and sensory categories that are ideologically and hierarchically arranged. AVT practitioners play what Ludwig Wittgenstein (2009) calls “language games,” and they also play sensory games and modality games, in that they have created and compartmentalized sensory, modality, and communicative categories.

As with cochlear implants, the emergence of AVT in India involves a “global re/habilitation community” organized around seemingly universalized principles and the production of an unmarked normal sensing subject. While there are only five certified AVT practitioners in India at the time of this writing, AVT has oversize importance in cochlear implant circles and is constantly discussed by implant manufacturers, surgeons, and speech and language pathologists as a “best practice.” (In addition to the five certified therapists, there are many practitioners in India like Zahra, who adhere to AVT principles and methods without being certified.) AVT certification and its possibility have brought new forms of internationally recognized expertise and prestige into re/habilitation circles in India.

In this chapter, I move from the United States to India and in time from the 1930s to the present, although other countries, notably Australia and England, have their own AVT pioneers and histories; there are Canadian, British, and Australian actors in the story I tell here. I traverse these spaces and times in order to flesh (or sense) out how deaf children’s senses are conceptualized. At stake is the value placed on the creation of a specific sensorium and sensorial way of being social. I end with a call for recognition of the value of multisensory and multimodal orientations and communicative practices—as well as the importance of attending to signals that are not just auditory. I argue for the importance of thinking about the affordances of all kinds of sensory signals and for a “social sense” that does not just emerge through listening and spoken language. In making this argument, I join with scholars of autistic sociality and communication and disability studies scholars who have labored to expand conceptions of communicative competence and ways of being social.2

Producing a “Normal Five-Sensed” Child

In November 1974, John Croft, the father of a then nine-year-old deaf child named Rose, wrote a passionate essay titled “The Third Way.” He argued that the contentious debate between oralism (a focus on promoting spoken language for deaf children) and manualism (promoting signed language for deaf children) obscured the existence of a third category and movement, which he called “auralism.”3 Croft (1974, 1), an education professor as well as the parent of a deaf child, argued that both oralism and manualism are imperfect, in that neither method can “teach an individual with only four senses how to compensate well enough to compete successfully in a world where others have five.” In contrast, Croft explained, auralist methods create “hearing-deaf” children who become “functionally mildly hard-of-hearing” through the training of their auditory sense (1). According to Croft, aural children can have conversations through walls, use the telephone, and hear their teachers regardless of where they are in the classroom. They do not need to read lips during spelling tests and can watch television. Aural children experience “five-sensed normality” (Croft and Croft 1978). What is required for “five-sensed normality” is a constant focus on audition, “until listening becomes as much a habit as looking, and feeling, and smelling, and tasting” (Croft 1974, 3).

In some ways, Croft’s admonitions and his concern with categories were ahead of the times, or at least we might initially think so. The principles and methods that he advocated are now called auditory verbal therapy, although at the time they were not gathered under any specific approach or name. Croft often discussed his own family’s experience with Rose in his writings and speeches. Rose’s hearing loss was not discovered until she was two years old. As a result of this so-called late diagnosis, her visual sense had a two-year “head start.” To counteract this, Rose’s family focused entirely on her auditory channel to make sure that it did not remain “deficient” (Croft and Croft 1978). When Rose was diagnosed, the doctor who examined her did not say that Rose could not hear. Rather, he said that she “does not appear to be using any hearing. Therefore, after providing proper amplification, we must begin immediately to teach her to listen” (Croft and Croft 1978, 2). Rose learned to listen through weekly therapy sessions with an AVT pioneer and by working extensively with her mother.

As Croft (1974) reported, whenever Rose’s mother or neighborhood children played with her, they did so in a way that encouraged her to use her hearing, rather than use her eyes to lipread (I wonder how Rose’s family monitored the neighborhood children). Rose was always in a “normal” classroom without accommodations, and her school records did not mention her deafness. She was permitted to hear “only normal sounds” and to “imitate normal speech” (Croft 1977, 4; Croft and Croft 1978, 5). Rose wore her binaural hearing aids from morning to night. A broken hearing aid was quickly repaired or replaced; she never went even three hours without a well-functioning hearing aid (Croft and Croft 1978). Throughout all of this training, her listening ability improved and her aided audiogram climbed up the chart. At the age of seven, Rose reached the borderline of “normal hearing at some frequencies” (Croft 1977, 3). According to Croft (1977, 2), his daughter and others like her are “hearing-deaf children” that have been a “remarkably well-kept secret.”

During the summer of 2019, I talked with Rose through a complicated setup of FaceTime, a CapTel phone (a landline phone with a small screen on which Rose could read what I said, as my speech was typed into text by a remote captioner), a Bluetooth hearing aid–compatible headset, and the occasional writing on paper held up to the screen. During our call, Rose told me that she learned as a child to “anticipate hearing,” which I took to mean that she became oriented toward sound. Growing up, she watched Sesame Street, Mister Rogers’ Neighborhood, and the evening news, where she enjoyed Peter Jennings’s and Ted Koppel’s voices; she found closed captioning distracting and unenjoyable when it became available (this is the opposite of my experience—I loved closed captioning). As a child Rose repeatedly had to listen to and identify the sounds of dogs, cars, cats, and airplanes, among others, as part of auditory training. However, she was not complaining and was proud to identify as an “auditory verbal person” and a “five-sensed person.” Rose’s parents wanted her to see herself as a hearing person first and a deaf person second; she said that they were successful.

Rose felt that her listening ability was still improving because of the way she had been trained to attend to hearing. She shared an example from her high school graduation ceremony, where, as a result of unusual grade point average calculations, there were many valedictorians and salutatorians. As she sat bored in the audience, various classmates were called to the stage and recognized as valedictorians and salutatorians; she heard those same words again and again. On the car ride home afterward, she complained to her mother about the many valedictorians and salutatorians. Rose’s mother expressed surprise to hear Rose pronounce these two words properly, as she had not been able to do so previously; she was able to pronounce them now because she had heard them over and over. Rose also told me about visiting a Mexican restaurant where she was able to pronounce a Spanish word after hearing it for the first time, offering this as further evidence of the fact that her auditory ability was still malleable and developing because of her rigorous childhood training.

At the end of our phone call, Rose said that, unbeknownst to her mother, she does lipread. When I asked why reading lips was so fraught, Rose told me that during childhood therapy, her therapist stood behind her and did not let her read lips. In a follow-up e-mail, Rose wrote: “AVT emphasized on LISTENING with our brain so anything to distract the use of ‘listening’ like lipreading can degrade the quality of your ‘listening’ muscles. So naturally lipreading was frowned upon. However as we get older our ‘brain’ is kidnapped to think and process many other things besides ‘listening’ so lipreading has become a supplemental support to the ‘listening.’ However it can overpower the listening component.” I am struck by the hostile language of kidnapping here and the need for a constant focus on audition, even in the midst of other life events. Laura Mauldin (2016) calls this “precarious plasticity,” the idea that there is always a risk of becoming visual. Even as an adult, Rose worries about her listening ability becoming overpowered by vision.

Rose’s words mirrored those of her father. In Croft’s essays and speeches, audition and “five-sensed normality” are contrasted with a deaf child’s tendency to become visual. Croft’s writings and speeches emphasize a battle between audition and vision and the need for vigilance to ensure that the visual sense does not win out. Crucially, and departing from the well-trafficked fight between oralism and manualism, this focus on audition adds something new to the mix—auralism. Mauldin (2016, 138) writes: “The therapeutic culture surrounding CIs [cochlear implants]—and especially the neuropolitical aspects of it—maps onto long-standing educational divides and serves to rearticulate past arguments for oral education in more sophisticated technoscientific terms.” More than this, it is important to consider the epistemological and ontological foundations of audition as a way of life; these underpinnings do not map onto the manual/oral debate and predate the emergence of cochlear implants—although cochlear implants offer new and unprecedented conditions of possibility for creating auditory children.

Unisensory

Rose’s therapist was an early auditory verbal therapy pioneer before the method was known by that name. Referred to in different circles as the unisensory approach, acoupedics, auralism, the auditory approach, the acoustic method, and natural language, what is now called AVT was originated by three women: Helen Beebe, working in Pennsylvania; Ciwa Griffiths, working in California and New York; and Doreen Pollack, working in Colorado.4 Trained in the 1930s and 1940s, all three traced their genealogies back to the same forebears: Austrian physicist Emil Fröschels, who developed the chewing method to help with stuttering; Viktor Urbantschitsch, an Austrian otologist who proposed theories of psychic deafness and offered up auditory gymnastics; and Henk Huizing, a Dutch otologist (Estabrooks et al. 2016; Goldstein 1933; Power and Hyde 1997). Helen Beebe’s archives at Penn State University contain letters written in the 1960s–70s between Beebe (note that she was affectionately called by her last name by those around her), Griffiths, and Pollack discussing their passion for their shared method and their sorrow that it was not universally known and valued.

Their method stressed that most hearing-impaired children, even those who are profoundly deaf, have some residual hearing that can be capitalized upon. Making the “maximum use of residual hearing which most have” requires that the child be “bathed in sound” and “surrounded by people who believe he hears,” as Beebe wrote on undated index cards.5 These three women, with their backgrounds working in deaf oral schools, were not satisfied with the ways those schools depended on visual methods such as lipreading. They also firmly believed that deaf children should be mainstreamed. In her elegant handwriting, Beebe wrote on a notecard a quote attributed to Alexander Graham Bell: “The best school for the deaf is the one with only one deaf child.” On another notecard, she recorded the observation that mainstreaming “can make the difference between a ‘deaf’ child and a normal child with hearing impairment.” This note makes it clear that Beebe believed that a child (like Rose) with a hearing impairment could become normal, depending on the kinds of sensory habits developed.

In a 1976 essay titled “Deaf Children Can Learn to Hear,” Beebe wrote:

In a unisensory program intensive auditory training means developing the use of amplified hearing to its maximum potential. Even profoundly deaf children can learn to hear. They can be brought to the point of handling conversational speech—repeating and discussing a story through hearing alone. They are not allowed to rely on lip reading until they are hearing oriented. Eventually they become multisensory. . . .

In early training we know that the child with one sensory receiving modality intact (sight) and one impaired (hearing) will rely on the easier modality and so we force him to listen and hear by preventing him from watching the speaker’s mouth. If our goal is to provide maximal use of residual hearing, he must be forced to hear enough to stimulate the motor speech center of the brain and to appreciate what hearing and discrimination can do for him. (241–42)

Beebe, like other AVT practitioners, was vigilant about intrusion from visual input and strongly believed that children could become hearing only if they were “forced” to use whatever hearing they had; this was the way to maximize potential. Only after becoming unisensory can a deaf child become multisensory. I also flag Beebe’s mention of the brain, which has come to occupy a significant role in shoring up the importance of creating auditory dominance in current AVT discourse (see Mauldin 2016; see also chapter 5 of this book).

Beebe’s unisensory approach, as established from the 1940s onward, called for early detection of hearing loss, appropriate binaural amplification (a new practice at the time, as previously children were fitted with only one hearing aid), intensive auditory training, a chewing approach that focused on making children aware of their chewing motions in order to develop natural voice quality, one-on-one therapy, educational placement with hearing peers, and full family involvement. Part of Beebe’s private clinic in central Pennsylvania was devoted to a model demonstration home, the Larry Jarret House, where families could stay for a week at a time and learn techniques for working with their children at home. Families from across the United States traveled to the clinic to receive instruction from therapists on how to maintain constant interaction with children during domestic activities (as I discuss here and in chapter 3, domestic spaces were key for utilizing and practicing AVT techniques). The Jarret House was also a demonstration space where visitors from near and far could witness the unisensory approach in action.

AVT’s formal beginning dates to two conferences on the auditory approach held in Pasadena, California, in 1972 and 1977. At the first conference in 1972, Beebe, Pollack, and Griffiths met in person for the first time. In 1978, the International Committee on Auditory-Verbal Communication was formed as a section within the Alexander Graham Bell Association for the Deaf and Hard of Hearing (known simply as AG Bell).6 One AVT practitioner and expert trainer I spoke with told me that the use of auditory in the therapy’s name is self-evident, while verbal was chosen to mark AVT as separate from oral therapeutic approaches, which do not require hearing. There are nonhearing and nonlistening oral deaf people, who, according to this trainer, often have exaggerated and artificial “deaf speech.”7 In 1985, an AVT certification process was proposed, as practitioners wished to differentiate their methods from those of other approaches (such as the auditory oral approach, which allows visual cues) and to have a credential that recognized AVT mastery.

In 1987, the International Committee on Auditory-Verbal Communication left AG Bell and formed an independent group called Auditory Verbal International. The members of AVI left AG Bell out of frustration that the association was not supporting auditory verbal approaches. In their eyes, AG Bell focused on oralism but not auralism. Many practitioners involved in AG Bell used visual-oral methods in residential and other deaf schools. There was also pushback against AVT from oral deaf adults who had not learned through audition (and who might have had “deaf speech,” in the words of the above-mentioned practitioner and trainer). AVT as an approach, especially its focus on mainstreaming, was threatening to administrators, teachers, and former students at schools for the deaf. Ironically, while these schools have largely focused on oral education, AVI saw them as “too visual” and having too much in common with proponents of sign language. In addition, AVT practitioners mostly worked in clinics and thus differed from therapists, teachers, and administrators in school-based settings.

AVI offered its first AVT certification examination in 1994. In 2005, after struggling financially and logistically, AVI reintegrated with AG Bell. Currently, the AG Bell Academy for Listening and Spoken Language oversees the AVT certification process (Estabrooks et al. 2016).8 At the time of this writing, there are approximately one thousand certified AVT practitioners internationally, with most concentrated in countries in the global North. The official designation for a credentialed AVT practitioner is Listening and Spoken Language Specialist Certified Auditory-Verbal Therapist (LSLS Cert. AVT). Another available credential is that of Listening and Spoken Language Specialist Certified Auditory-Verbal Educator (LSLS Cert. AVEd). The former is the credential usually sought by therapists who work one-on-one with children and families, while the latter is intended for those likely to work in schools.9 The latter certification, according to a prominent AVT practitioner, is controversial because a fundamental premise of AVT is that deaf children should be mainstreamed (recall the quote above attributed to Alexander Graham Bell and singled out by Beebe). The AG Bell Academy, through its certification authority, has control over who can call themselves AVT practitioners or say that they are “doing AVT.” Therapists without AVT certification often stress that while they are not certified, they do use AVT principles and methods. They might also call themselves auditory verbal habilitationists or practitioners of auditory-based therapy.

Certification requires a degree in a deaf education or re/habilitation-related field, mentorship by a current certified LSLS AVT professional (which the potential AVT practitioner might pay for), and successful completion of an examination administered in either English or Spanish at a licensed testing center. Once certified, AVT practitioners must abide by the following ten principles, as stated by the AG Bell Academy:

1. Promote early diagnosis of hearing loss in newborns, infants, toddlers, and young children, followed by immediate audiologic management and auditory-verbal therapy.
2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation.
3. Guide and coach parents to help their child use hearing as the primary sensory modality in developing listening and spoken language.
4. Guide and coach parents to become the primary facilitators of their child’s listening and spoken language development through active consistent participation in individualized auditory-verbal therapy.
5. Guide and coach parents to create environments that support listening for the acquisition of spoken language throughout the child’s daily activities.
6. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child’s life.
7. Guide and coach parents to use natural developmental patterns of audition, speech, language, cognition, and communication.
8. Guide and coach parents to help their child self-monitor spoken language through listening.
9. Administer ongoing formal and informal diagnostic assessments to develop individualized auditory-verbal treatment plans, to monitor progress and to evaluate the effectiveness of the plans for the child and family.
10. Promote education in regular schools with peers who have typical hearing and with appropriate services from early childhood onwards.10

Consider, in particular, the third principle, which calls for hearing to be the “primary sensory modality,” and the sixth principle, which calls for listening and spoken language to be integrated into “all aspects of the child’s life.” Engagement with the world is supposed to occur through audition. AVT professionals now “guide and coach” parents just as much as they work directly with children. This novel focus on parents differs from the work that the early pioneers did with deaf children in that therapists now model techniques for parents, instruct parents in what to do, and help them develop listening and spoken language–rich activities to do with their children at home. As I discuss in chapter 3, this focus on coaching parents has particular ramifications for deaf parents who are considered not appropriately sensible or social because they cannot use listening and spoken language themselves as well as for any parents who are overworked and overwhelmed.

In June 2018, I sat in a packed, heavily air-conditioned conference room at an AG Bell annual convention held at a five-star resort in Arizona. Audiologists and AVT practitioners, including a few therapists from India, were listening to Carol Flexer, a leading figure in AVT. Flexer resembles a preacher with her animated demeanor and use of chants and repetition, all oriented toward the importance of the brain. She led participants in a call-and-response chant: “The ears know nothing, the eyes know nothing, and the nose knows nothing. It is the brain that knows everything.” She stressed that deaf children have hearing brains. They have doorway problems and need “doorway devices” such as hearing aids or cochlear implants to help access the brain. Children must wear doorway devices from the earliest age possible, and the brain must be stimulated during every waking hour. As Flexer and Ellen Rhoades (2016, 24) have written: “We hear with the brain; the ears are the doorway to the brain for auditory information. Consequently, hearing loss is primarily a brain issue—not an ear issue.”

In contemporary AVT worlds, a deaf child is a child with a hearing brain and a closed doorway to that brain. This concept of “closed doorways” reminds me of the oft-cited statement attributed to Helen Keller: “Blindness separates us from things, but deafness separates us from people.” For AVT proponents, deafness is not only a “closed doorway to the brain” but also a closed social doorway between people, because communication and sociality can take place only through listening and spoken language. Listening and spoken language are thus instrumental for developing a social sense and participating in the world. The workings of the brain are ultimately exteriorized and socialized in that families must learn, scaffold, and perform (“guide and coach”) appropriately social and communicative behavior, as outlined in the principles of AVT, to unleash the brain’s potential.11

The senses are scaffolded and isolated into what Caroline Jones (2005, 389) calls a “modernist sensorium,” and there is a manufactured war between hearing and vision. For example, in an AVT handbook, Flexer and Rhoades (2016, 30) provide “important definitions” for the concepts of “sensory deprivation,” “sensory compensation,” “sensory competition,” and “sensory dominance.” These concepts are often discussed in the context of a battle between vision and audition and the need to avoid visual dominance (also see Mauldin 2014, 145). Where are the other senses and how might we take a more cooperative view of the senses working together? In response I argue that we must sensorially stretch the social beyond a binary between vision and hearing and examine how the social can be produced and inhabited in diverse and expansive intersensory and multisensory ways. I am referring here not to what Maurice Merleau-Ponty (1962) calls the prereflective unity of the senses, but rather to the ways that different senses can be cultivated or constrained. Unity is not prereflective or presocial.12

Modality Continuums

To be sure, AVT is not the only method used to achieve listening and spoken language results. Therapists, families, and older deaf adults in both the United States and India told me about techniques that involved visual and tactile cues: focusing on a therapist’s lips, feeling throats for vibrations, vocalizing onto feathers, and forcing air out of one’s nose and monitoring the sensation, among other things. (These techniques are typically not romanticized or thought of nostalgically; I too have memories of throat vibrations and articulation exercises during my weekly speech therapy sessions.) With improved hearing aid technology and the normalization of cochlear implants, therapists stress that now it is easier than ever before for children to attain good listening and spoken language outcomes through unisensory approaches, especially when the children are implanted at a young age. Many multisensory techniques have gone by the wayside.

Janet, an American therapist who works internationally, told me: “Children hear so much more now. It used to be that with profoundly deaf children, they really relied on their eyes because they only got a very narrow part of the speech spectrum with their profound hearing loss. And you could develop wonderful speech and language through that very narrow bit that they got. But it was hard work. And you did kind of have to force it a bit, because they were very visual.” While therapists constantly told me how much easier their work has become since the advent of improved technology, it is clear that more labor has been foisted onto families (particularly mothers).13 Increasingly, audiologists and therapists argue that there is no reason why a deaf child diagnosed early enough should not have access to listening and spoken language—although there is always the lingering question of what to do with older children.

Similar to Wittgenstein’s (2009) “language games” and the accompanying sensory games and modality games in AVT worlds, AVT practitioners speak of communication options, communication opportunities, and communication outcomes. Options are evaluated according to whether they are more or less auditory or visual and the kinds of outcomes they produce. The AG Bell website lists and describes “four primary communication outcomes, each tied to an approach to language”: listening and spoken language, cued speech/language, American Sign Language/bilingual-bicultural, and the total communication method.14 While AG Bell addresses these as four distinct and differentiated options, practitioners often speak of a “communication continuum” or a “communication spectrum,” although this spectrum is made up of bounded categorical approaches to communication. (How can there be only four ways to communicate?)

While AVT practitioners and many families of deaf children strive for what they call the “gold standard of listening and spoken language,” what happens on the ground—in clinics, schools, and homes—is not bounded, and an array of senses, modalities, and ways of being social exist. People might be aural and oral, and also use some gesture and sign language, for example, or they might do something else entirely. Outcomes can never be preplanned or guaranteed, despite the clear categories and labels that have been set up for different therapeutic and communicative approaches.

In India, neither cued speech nor the bilingual-bicultural approach was in use at the time of my research, although educators and deaf activists had been advocating for a bilingual-bicultural approach. In addition, “total communication” was an amorphous, catchall category. I had many conversations with therapists in India and the United States in which we confused ourselves about what different techniques entailed: What does it mean to be “auditory oral,” “auditory aural,” and/or “auditory verbal”? When is lipreading permitted or not? How do you know when someone is lipreading or what senses a person is using to communicate? Communication can escape categorization.

But how to talk about “oral failures,” or, in this case, “aural failures”? Janet told me that she advocates for AVT practices to be “diagnostic” and for therapists to evaluate children each time they see them while also having three-month, six-month, and long-term goals. She stressed that there is no such thing as a “failed AVT child.” She said that some children simply need “something else”: “I think in AV[T] we see that the full communication continuum is essential. Every communication method must be a choice. And in AV[T] if a parent chooses spoken language we start at the far end of the continuum and diagnostically assess the child. And if they’re not making the progress they need to, we keep moving along the continuum as far as we need to until that child’s rate of progress is appropriate.” According to Janet, sometimes children just need “information in a different way.” Janet’s focus on choice ignores the power- and value-laden terrain and the fact that many families are not presented with any choice—as I saw firsthand with families with whom I worked. There was no “something else” for them. In addition, Janet’s ostensibly diagnostic and scientific approach prevents AVT from ever being a failed method.

While Janet stressed that children never fail, I am reminded of a story that I heard more than once while visiting an institute in Kerala that offered both early intervention programs in listening and spoken language for small children and university-level courses taught in Indian Sign Language. The institute was starting a bilingual early intervention program in which it would teach ISL as a first language in which to then teach reading and writing in Malayalam. The program coordinator told a mother of a deaf child that her son was not successful in the listening and spoken language early intervention program and that she recommended transferring him to the bilingual class. Upon hearing this, the mother fainted (or at least that is what multiple people told me) because she was so distraught about her son learning ISL and not spoken language (also see Friedner 2018).

As David Howes and Constance Classen (2014, 5) write: “Equally significant to the ways in which the senses are practiced are the ways in which a society decides that they should not be used: when and what we must not see, or touch, or taste.” There are distinct sensory politics and ideologies at play here. It might seem that a focus on the brain, what Elizabeth Fein (2020) calls the “neurodevelopmental turn,” renders the terrain apolitical, as deaf children ostensibly have hearing brains and are harnessing their potential to be auditory. These neuro-claims, however, are politically fraught despite the fact that neuroscientists conducting brain research do not make any normative claims about any particular configuration of the sensorium being more or less optimal.15 In AVT circles, a normative value is placed on audition above all else. Ideological claims are made that audition is the “fastest sense” and that auditory dominance can result in improved academic performance (Flexer and Rhoades 2016, 24, 29). These references to speed and performance also point to the importance of functioning optimally within capitalist systems (Malabou 2008; Martin 2007). And let us not forget that the channeling of potential occurs through exteriorized social, familial, and educational scaffolding; the work of “forcing” a child to hear happens in the domain of therapeutic and everyday life.

AVT in India

As noted above, there are currently only five AVT practitioners in India, although there are therapists working toward certification and others who hope to become certified in the future. Certification is an achievement and a class, educational, and linguistic privilege, because of the foundational training in speech and language therapy required, the monetary expense, the time and mentorship required, and the fact that the certification exam is administered only in English and Spanish. As one certified therapist in India told me, having AVT certification opens doors to domestic and international conferences (such as the one mentioned above) and to consulting, as well as to membership in a global AVT community. Two of the certified therapists currently operate their own clinics, two are employed by a cochlear implant manufacturer, and the fifth runs a parent advocacy organization; all conduct short-term AVT courses and trainings around the country, consult with other clinics and practitioners, and give lectures. They also mentor other potential AVT practitioners and conduct remote or video sessions with families and deaf children in other countries.16 When I visited the two therapists with their own clinics, the cochlear implant company posters on the walls and the abundant (often imported) toys and books throughout made me think I could be in a U.S.-based clinic. At the same time, I was aware that these were only two of many clinics in India, and that, for the most part, these therapists served both carefully chosen and self-selected elite and upper-class families (although one therapist worked with a foundation that provided free implantation to children below the poverty line).

As more children and adults in India become implanted, AVT practitioners and cochlear implant corporations stress that additional AVT specialists are needed. Current AVT practitioners have been lobbying the Rehabilitation Council of India for an AVT course, and a cochlear implant corporation is currently working with the Ali Yavar Jung National Institute of Speech and Hearing Disabilities to run an AVT diploma course. There is an ongoing debate in professional speech and language therapy circles about who has sufficient skills and training to work with implanted children and whether the existing audiology and speech and language pathology curriculum, which includes multisensory approaches, is sufficient. AVT expertise is surrounded by much gatekeeping and boundary policing. For example, at the 2019 conference of the Cochlear Implant Group of India, a certified AVT practitioner chided another therapist who was not certified for saying that she practices AVT with children.

In addition to policing each other and staking out a unique professional space of their own, AVT practitioners express frustration with surgeons and audiologists, who, they claim, do not value them. Speech and language therapists do the most important work with families and children on their cochlear implant journeys, these therapists argue. The often-repeated mantra is that surgery is 10 to 20 percent of the work of implantation, and the rest of the work is therapy.17 An agitated therapist stood up in the Rehabilitation Hall at the 2019 CIGI conference and said: “The surgeons need to be in here listening to these presentations. They need to see how important our work is and not just focus on numbers of surgeries done.” (Only one surgeon attended sessions in the Rehabilitation Hall, which was the conference’s smallest and most sparsely attended presentation room; the largest and most crowded was the Surgical Hall, followed by the Audiology Hall.) I mention this therapist’s sentiment to point out the larger terrain of contested skill in which AVT practitioners and other therapists work. AVT practitioners told me that they must work constantly to prove their value to surgeons and families, especially because they have made large financial and time commitments to an international certifying body, charge higher fees than many other therapists, and run specialized practices.

In addition to critiquing surgeons for not valuing them, AVT practitioners differentiate themselves from speech therapists. For example, a certified AVT specialist named Aruna criticized current Indian therapy practices by stressing that speech therapists in India focus only on speech, not language. She said that therapists teach children as if they are parrots, drilling them to repeat words.18 This is something that mothers might do as well and that AVT practitioners try to rectify: in an AVT session in Mumbai that I observed, a therapist worked with a mother of a three-year-old boy who was recently implanted. The therapist wanted to make sure that the mother was not instructing her child to repeat words. The mother had been saying, for example, “Say pencil,” or “Say giraffe.” The therapist told her that this practice was not helpful to her child; instead she should have “natural conversations” with her child in which they take turns talking.

Aruna told me that she teaches language through AVT principles, in contrast to what she considers to be “drill-based” and “unnatural” speech therapy.19 She “stimulate[s] the auditory brain, at least for children under five,” because “audition is the only modality through which fluent and perfect speech can develop.” In addition, children older than three who are “habitual lipreaders” can be made into auditory listeners through techniques like the “auditory sandwich,” which involves first speaking without letting the child see your lips, then repeating and allowing the child to lipread, and then “closing” the sequence by saying the same thing with only audition again.20 This method uses carefully scaffolded and hierarchically organized sensory sequencing—listening before seeing and then listening again—in order to create appropriate sensing.

Aruna said that the most important part of her job is helping children become appropriately social. Similarly, another AVT practitioner, emphasizing the social work that she does, said that she teaches children not only language but also conversation. In her words: “A lot of these children have the language, [but] they don’t have the conversation, they don’t have the conversational skills, they don’t have the social skills.” Social skills are defined as engaging in dyadic turn-taking and in contextually sensible and linguistically expansive conversation. AVT practitioners in India and elsewhere stressed that the children with whom they worked were not only age appropriate in their general knowledge, language, and social skills but often ahead of their peers—all of the therapy had paid off.21 AVT is thus envisioned as creating highly social and intelligent children. However, speech, specifically nondeaf speech, is still the goal. (Aruna was particularly concerned with ensuring that children did not have “deaf speech” or “deaf accents.”) What about other parts of the brain and forms of life more generally that are not stimulated?

Aruna became an AVT professional through her personal journey with her deaf son. After he was diagnosed, she toured different centers and educational institutions across India. She was unsatisfied because she did not meet deaf children with “good speech” or who were using the latest hearing technologies. Aruna learned about the well-known correspondence course offered by the John Tracy Center, through which she received a curriculum in the mail, and she attended one of the center’s international summer clinics in Los Angeles.22 She also spent thousands of dollars purchasing every book available from AG Bell. She was excited to learn about cochlear implants, and her son became one of the first implanted children in India at the age of two. Aruna’s primary goal is to teach parents to work with their deaf children, and she does this in her cozy and cheerful clinic full of imported books and toys; she does creative art projects with the children and hosts music sessions for them as well. Because her clinic is full of multisensory endeavors, whenever I visited I was always taken aback by the constant return to audition.

I frequently asked therapists about isolating audition. On one hand, therapists were quick to tell me that during typical conversation we use all of our senses. As one of them put it, “When we sit together and talk, we look at each other, we use all of our senses.” On the other hand, therapists emphasized that such conversation cannot happen automatically with deaf children: they need training to become five-sensed (to use John Croft’s words). Initially, then, the therapist must focus solely on audition. Other senses can be engaged only once the child is “confident” in audition and the therapist is certain that the child depends on audition and has a robust “auditory system.”23

However, this privileging of audition is the goal only for children who are young enough and do not have other disabilities. One therapist told me that for children with multiple disabilities she makes “concessions”: she makes her lips “available to the child and will sit facing the child.” Concessions and reliance were two concepts that therapists used to discuss visuality. Why not think instead about the affordances of different communication modalities and look at multisensory engagement positively? Indeed, in their work on normative communicative engagement, Elinor Ochs, Olga Solomon, and Laura Sterponi (2005, 560) point out that “communicative habitus is not neutral with respect to its influence on children’s development, in the sense that habitus does not necessarily maximize communicative potential.” What are some other means of cultivating potential and reimagining communication?

While I sat with Zahra in anticipation of an Indian Independence Day celebration at her center, a ten-year-old girl in a flowing orange dress and green-and-white barrettes came over to her to say hello and to ask why Zahra was not wearing any orange, white, or green clothing, as everyone had been told to dress in the colors of the Indian flag. Zahra gently turned the child so that she was facing away from her and leaned over to speak into her ear. She said that she had forgotten to dress up, and she asked the girl if she was going to sing the national anthem as part of the celebration. She held the girl’s waist tenderly and spoke warmly. When I asked Zahra about how she communicated with the girl, she said that the girl could hear across the room, but she had always liked physical contact. She had insisted on sitting on Zahra’s lap when she first attended the center as a small child. As she grew, she became too heavy for a lap, but she still needed touch, Zahra said. Here a touch served as an anchor, under the radar, as a supplement to audition, another form of engagement, or a means of cultivating potential, depending on how you look at it. Touch, as Erin Manning (2007, xv) argues, can be a form of relational worlding: “The proposition is that touch—every act of reaching toward—enables the creation of worlds.”24

Six Sounds

Use of the Ling Six sound test is an important practice in AVT clinics and educational spaces, as well as in domestic settings. During this test, performed by a therapist, teacher, or parent, the child’s back is turned to the speaker, so that the child cannot see the speaker’s mouth. The speaker utters the following phonemes one at a time and waits for the child to repeat them back: [m], [ah], [oo], [ee], [sh], and [s]. These phonemes broadly represent the speech spectrum from 250 to 8,000 hertz and thus target and include low-, middle-, and high-frequency sounds. These sounds represent what is known in audiology and speech and language pathology worlds as the “speech banana” (as described in the Introduction) and encompass the frequencies of everyday speech and talk; this spectral range is the same as that tested by conventional audiometry. The Ling Six sound test is both diagnostic, in that it can identify whether assistive devices such as hearing aids or implants are working, and pedagogical, in that it aids in the child’s detection, discrimination, and identification of speech. If a child can listen to and repeat the Ling Six sounds, this demonstrates that the auditory sense is primed and that the child is ready to listen.

I sat in early intervention classrooms in India where teachers called children up to the front of the room one by one to sit with their backs to them while they uttered the Ling Six sounds. I also observed children collectively reciting the sounds back in singsong cacophony. I visited clinics where therapists sat next to children, albeit carefully positioned so that the children could not see their mouths, and recited the sounds. It was easy to tell which children were new to the practice because they appeared unmoored: they tried to turn around and look at their teachers or therapists to read lips or seek assurances about whether their utterances were correct. In response, the teachers gently turned their heads back away. Children who were familiar with the Ling Six sounds were confident and repeated them effortlessly.

One Sunday afternoon I sat with a young boy and his mother as the mother and I talked about the work that she was doing to raise her son, specifically the work of talking to him constantly. She asked me about my earlier visit to her son’s school, and I told her that it was interesting to see teachers doing Ling Six sound tests individually with children while the other children sat and gestured (quietly but noisily) with each other. She interrupted my observations to stress the importance of the Ling Six sound test, noting that she did it daily with her son. She called her son over for a demonstration, and he sat on the floor in front of us with his back to us. She said the sounds softly and he repeated them, with a smile on his face. He then wanted to give a friend sitting with us the same test, and he had her sit in front of him while he said the sounds—“mmmmm,” “ahhhh,” “oooooh,” “eeeee,” “shhhhhhh,” and “ssssssss”—and she repeated them. This was all done with smiles and laughter (it was a performance). The work of mastering and repeating these sounds has become a meaningful communicative practice and routine, a familiar ritual, that binds this mother and son together.

This mother had learned that the Ling Six sound test is a way to check that her son’s hearing aids are working and that the hearing aids, child, and environment are interacting. She said that her son’s listening to the six sounds and responding to them establishes that communication, teaching, and learning can begin. While she did not talk about this process in terms of signals, the Ling Six sound test detects whether auditory signals are being transmitted and received. It does not measure the emotional quality of these signals or the roles of other pathways and motivators in facilitating these signals. For example, in Zahra’s conversation with the young girl, her gentle and loving touch might have helped the auditory signal reach the girl’s ears.

How might we think of the role of emotion and desire in enabling the transduction of waves into the sounds that become the Ling Six sounds and communication in general? As Stefan Helmreich (2015, 226) states: “Transduction is the result of work, of labor that, when done well, produces a sense of seamless presence, presence we should not take for granted but rather should inquire into as itself a technical artifact.” In this case, mothers do the difficult work of uttering and repeating these sounds while children labor to detect, discriminate, identify, and comprehend them; nothing about this process can be considered, in Helmreich’s words, “seamless.” The process itself is an example of what Jonathan Sterne and Tara Rodgers (2011, 48) term “signal labor.” Neuroscientists have recently argued that deaf children and adults do additional work, or engage in increased listening effort, to receive what have been called the “degraded” or “impoverished” signals transmitted to them through hearing aids or cochlear implants.25 According to this research, deaf children and adults work harder than nondeaf people to process information, and they need to recruit greater cognitive resources. Signal labor, indeed.

Carina Pals, Anastasios Sarampalis, and Deniz Başkent (2013, 1075) state that “listening effort can . . . be defined as the proportion of limited cognitive resources engaged in interpreting the incoming auditory signal. It has been suggested that the presence of noise or distortions in a speech signal increases cognitive demand and thus listening effort.” I am not interested in claiming that deaf people with hearing aids and implants work through degraded signals (that is deficit framing). I am, however, invested in analyzing the stakes of the additional labor required and the way that a focus on audition assumes that there is only one signal or stimulus deserving of attention. AVT practitioners stress that noise is anything other than the target stimulus, which is speech.26 Who decides what the target stimulus is? Noise is considered to be “antisocial” and a threat to the dominant social order (Novak 2015, 126); it gets in the way and obstructs the signal. However, we might also consider how noise offers up different social and relational cues as well as access to different signals. Marie Thompson (2017, 3) argues that noise is “a productive, transformative force-relation and a necessary component of material relations.” There is no signal without noise.27

The Hand Cue

According to AVT practitioners, visual noise interrupts or prevents the reception of the auditory signal. Rose Croft’s therapist did not stand in front of her and often walked around during their sessions. Two of Beebe’s former students told me that Beebe did the same during sessions, and sometimes Beebe instructed them to face the wall so that their backs were to her. Beebe was strict, they said, and this was an example of “tough love.”

When therapists and parents cover their mouths with their hands while speaking with deaf children to foreclose the possibility of lipreading, this is called the “hand cue.” One does not just obstruct one’s mouth: one uses a flat hand, angled slightly away from the mouth, and at least a few inches off the face, in order to minimize sound interference. On blogs and in chat rooms, therapists and parents discuss how to perform the hand cue properly: Should the hand be angled at forty-five degrees or ninety degrees? How far from the mouth should the hand be? Other ways of preventing lipreading include holding a book or a screen of some kind in front of the mouth, as well as the “natural” techniques of “visual distraction” (holding up stuffed animals, for example) and “joint attention” (focusing the child’s attention on toys, books, or other objects rather than on the speaker).

While sitting in waiting rooms or in therapy sessions, I often saw mothers covering their mouths or tilting their heads away from their children. Sometimes their actions were obvious, but other times they were more subtle—a hand on a cheek, cupped fingers over a mouth. During a therapy session, the therapist and parent sit alongside or slightly behind the child and not across from the child, in order to minimize the possibility of lipreading or other visual cues. The hand cue, when used in its simplest and most obvious form, prompts the child to begin “listening.” It functions like another popular cue: pointing a finger at an ear and commanding the child to “Listen!” As Talbot (2016, 12) notes regarding the hand cue: “Children quickly learn that when the adult’s hand is in place, they are expected to be listening. You may see the young child start to cover their mouths as they talk in the early stages of Auditory-Verbal Therapy.” Children addressed in this way will do the same, as they see it as the appropriate way to engage with others.

The hand cue is designed to “integrate the five senses” (Rosenzweig 2011). According to this sensory ideology, isolation results in integration. However, I do not see what is sensorially evocative or social about covering one’s mouth. Critics of this method argue that it obstructs or impedes sound from reaching its recipient, it is unnatural, and it is socially awkward; this concern about “social awkwardness” is compelling because AVT practitioners stress that they teach children to be social participants.28 Covering or obstructing one’s mouth when talking can be a barrier to joint attention at the same time it is ironically supposed to signal that it is time for listening and speaking. And thinking about signals, the hand cue also impedes other kinds of multisensory, multimodal, and multipersonal communication. Why not increase sensory input and signals all around? How might children benefit from multiple forms and modes of signals, especially considering that these children work through degraded auditory signals? AVT practitioners typically do not discuss deaf children’s and adults’ signal labor (Sterne and Rodgers 2011) or their greater cognitive load and effort.29

Stripes

In September 2018, I attended a training conducted by Purnima, an Indian AVT specialist. The training was for audiologists and speech and language pathologists in Delhi, and it included a discussion of an AVT case, which Purnima stressed was not a “star case.” She introduced the case as follows: The child was two years old. Her parents wanted her to learn English and eventually attend an English medium school, although their primary language was Marathi. However, the mother’s English was “not natural and the father did not speak English at all”; in pointing this out, Purnima was also indirectly providing the information that while this family was middle-class, they were not part of the English-speaking elite. When the girl’s mother sang “Twinkle, Twinkle, Little Star,” she sounded artificial and rocked her arms from side to side, giving visual cues. Purnima thus suggested that the family switch to their mother tongue, Marathi, which “provided a full language environment.” (“Full” is an interesting choice of adjective.) According to Purnima, switching to Marathi fulfilled the principles of AVT in that language should be natural, meaningful, and relevant. With Marathi, the child could communicate with her grandparents at home in their joint family household. In addition to hearing loss, the child had seizures and facial dystonia. Purnima had contacted the child’s neurologist to learn about the seizures; Purnima stressed that her work also focuses on the brain, and she emphasized her role as a health professional and team player. In order to pay for the child’s cochlear implant and surgery, the family sold their house and all of their gold. The mother said that she would need to buy gold for her daughter’s marriage in the future, but she preferred to spend money on a cochlear implant now. (A cochlear implant now would ostensibly make it easier for this mother to find a good husband for her daughter in the future.) Purnima also told the mother not to work outside the home for three years, or “there would be no hope for the child.” The family’s long-run developmental trajectory was thus abandoned in favor of the child’s development in the present. Slowly, Purnima said, “the child started becoming normal.”

After giving us this case context and details, Purnima showed us a video of a session with the family. In the video, we saw the girl’s mother, Purnima, the girl, and her father (in that order) sitting on one side of a small wooden table in a cozy therapy room. There were bright pictures behind the table, a tablecloth and a pitcher of water on the table, and toys on the floor in various bins. First the group discussed who wanted water and who would pour it. Then they examined a bin with plastic animals and discussed the animals they saw. Purnima planned to introduce the topic of “stripes” in this session. Before the session, she called the father to tell him to wear a striped shirt, and she too wore stripes. (The mother did not own a striped shirt.) During the session, Purnima pointed to the striped shirts, and a “natural” discussion about stripes took place.

Throughout her running commentary to us as we watched the video, Purnima stressed how much planning goes into lessons; nothing is done without premeditation. Lessons are carefully tailored to the family (and not just to the deaf child’s brain), with specific activities and goals documented in lesson plans. Her goals for this lesson were to expand the child’s language and move her from one-word to multiple-word responses, to encourage her to use social communication such as “please” and “thank you,” and to introduce “stripes.” Purnima finished this overview of her lesson by telling the therapists present, “In the past, we did therapy in very difficult situations. Your situations are much easier.” She said that today’s therapists have better technology, more sophisticated toys, and less noisy rooms. Just as deaf children have access to better technology, so do AVT practitioners. Her implication was that there is no excuse for not attaining a listening and spoken language outcome.

In a forty-five-minute session I observed with a different therapist in Mumbai, a three-year-old boy, his mother, and his grandmother were invited into the therapy room after they had taken turns knocking on the therapy room door. This activity was designed to demonstrate sound detection. After settling around a small table and starting with the Ling Six sound test, the therapist playfully read a picture book about jungle animals with the child and then facilitated a sequential ordering exercise with cards featuring pictures of a boy with balloons that are subsequently popped. In a final activity, the child was given a doll to place in different positions, such as sitting, eating, and sleeping. Throughout the session, the therapist patiently explained to the child’s mother what she was doing and why. Every activity had a goal. The therapist was working on audition with the book about jungle animals; the card sequencing was for cognition, vocabulary, and emotions; and the positioning of the doll was to teach verbs.

The AVT sessions that I observed were happy, playful, and engaging. A young adult told me that he loved therapy as a child because adult attention was showered on him and he was able to play with toys and read books. A U.S.-based AVT practitioner stressed that she wanted her therapy sessions to be the highlight of the children’s week, and that she measured success initially by whether or not the children and their families were smiling during sessions. However, despite the existence of toys, books, creative projects, and enthusiastically inflected speech to anchor, contextualize, and animate these literal “language games” (Wittgenstein 2009), multiple modalities are not permitted in most AVT sessions. Despite the nurturing and lighthearted manner that permeates these sessions, in which work and play are intertwined (Goodley and Runswick-Cole 2010) and “magical and pretty worlds” are created (Mattingly 2010, 209), there are hard boundaries around what is acceptable in terms of communicating and relating in AVT sessions. It is also difficult for me to fully be at home in a space where lipreading is considered taboo, where such a signal—and form of connection—is blocked. I have a vivid fieldwork memory of an AVT session in which an animated therapist spoke but also gestured. The five-year-old boy with whom she worked had eyes that darted constantly to look at her hands, seemingly searching for a meaningful signal.

Everything

I contrast these AVT sessions with another session I observed, also with a three-year-old child who had recently been implanted, this time in Pune. The therapist was a young woman named Tanima who worked with a large caseload of deaf children from all over Maharashtra. Mothers and their children arrived at the clinic for their therapy appointments after long bus journeys. The stakes were high, in that if the child was tired or hungry, the forty-five-minute session would not go well. In this session held in a small, brightly lit therapy room, Tanima perched directly in front of the child, who sat in an old-fashioned wooden high chair. The girl’s mother was positioned next to Tanima, and two young interns sat next to the girl. When I arrived, the group was reading a picture-book story about a bear participating in different activities of daily life, from getting dressed to brushing teeth to playing with friends. The child looked sleepy and distracted. Tanima worked to engage her by constantly talking to her in an animated and enthusiastic way, showing her the pictures in the book and moving her hands to touch them, and gesturing. After reading the book, Tanima, the interns, and the girl’s mother asked the girl to pass them objects in front of her, and when she did, they said, “Aacha!” (Good!) and used a hand gesture. The session included touching, gesturing, miming and mimicking, looking at pictures, talking, and listening. I was struck that Tanima sat directly in front of the girl, made eye contact, and actively manipulated her hands, trying to get her to communicate. She was like a marionettist in her work to animate the girl, although the goal was for spoken language to emanate from the girl herself without facilitation or prompting.

When Tanima and I discussed her creative use of different modalities, she said that she just “knew” what to do in the moment and that she was not following a method. Tanima had been exposed to a stream of international visitors sharing AVT and other auditory therapy methodologies, many of these visits sponsored by cochlear implant companies. Tanima said that she “learned many approaches from different people . . . but we do whatever the child needs.” The claim of providing “whatever the child needs” was something I heard from other therapists as well. They criticized what they called the elitist bias of AVT and stressed their desire to do whatever it takes to allow communication and development to happen. State-employed therapists in particular stressed that they could not focus only on AVT because, unlike therapists who can “cherry-pick” the families with whom they work, government therapists must work with all families. These therapists discussed the importance of “total communication,” a term often used to refer to the use of gesture with some Indian Sign Language lexicon as well as visual and tactile modes of communicating. Many AVT practitioners, surgeons, audiologists, and others speak of “total communication” as negative, sloppy, and unrefined, an approach of last resort. In this conception, total communication is not language, and it certainly is not listening and spoken language. However, there are other ways of defining total communication.

According to Mervin Garretson (1976, 89) and Lionel Evans (1982, 21), total communication is a philosophy and not a method; it is meant to be flexible and person centered. It does not map onto manualism or sign language; rather, it combines “aural/oral-manual modes according to the communicative needs and expressive-receptive threshold of the individual” (Garretson 1976, 89). More than this, total communication supports “the moral right of the hearing impaired, as with normally hearing bilinguals, to maximum input in order to attain optimal comprehension and total understanding in the communication situation” (Garretson 1976, 89). Total communication draws upon speech, sign, gesture, finger spelling, pantomime, drawing, writing, and touch—it can involve all modalities, and it is designed to meet the needs of deaf people (and presumably all people), whatever they might be (Evans 1982).30

This approach articulates with Margaret Mead’s ([1964] 1972) use of the concept of “total communication,” which she introduced in a conference presentation titled “Vicissitudes of the Study of the Total Communication Process.” Mead stressed the importance of attending to and valuing multimodality across the disciplines and called for a more nuanced study of communication beyond linguistic utterances. With this in mind, it makes sense that those focused on auditory verbal approaches would be critical of total communication as a philosophy and as an approach, as it expands how we think about communication beyond language. Total communication could also be considered an example of what Pentcheva (2006, 631, 650) calls synesthesis, or “consonant sensation,” situations in which “sight, touch, hearing, smell, and taste are engaged simultaneously.” If listening is supposed to be a (unisensory) way of life, total communication functions as a threat, as does the potential unruliness and nonnormativity of a multisensory and multimodal approach.

I hold on to the concept of total communication as a provocative and aspirational philosophy because it opens up possibilities for communicating outside of standard categorical statements about what communication is and is not. I do not know how it would unfold as a systematic method, but I imagine that it would draw upon what Charles Goodwin (2017) terms “co-operative action” and what Mara Green (2014b) conceptualizes as people’s moral orientation and attunement toward making communication successful. Total communication as analytic and approach resonates with recent work on multimodality in deaf studies and sociolinguistics. Annelies Kusters et al. (2017) call for attention to deaf people’s diverse semiotic repertoires as a way to depart from an approach that sees languages as bounded and unimodal systems. Instead, they argue, people bring a multiplicity of modes with which to communicate. As they note, “Blommaert and Backus (2013) explain that ‘A repertoire is composed of a myriad of different communicative tools, with different degrees of functional specialization. No single resource is a communicative panacea; none is useless’” (222). The idea that no single resource is a panacea is important to consider in light of the value focused on listening and spoken language. Indeed, as Kusters et al. observe, attending to semiotic repertoires enables “a holistic perspective, taking into account inequalities and power differences by paying attention to hierarchies of resources, and to lack of accessibility to resources” (228). I share their concerns with the ways that semiotic resources are differentially valued in the creation of communication—and communication categories—and I am also concerned with sensory access (also see De Meulder et al. 2019). Additionally, I am interested in destabilizing the value affixed to different sensory modalities and the creation of distinct sensory repertoires and hierarchies of the senses.

The immense diversity of semiotic and sensory repertoires is left out in the binary created between manualism and oralism, the focus on aurality as unisensory and unimodal, and the creation of neat communication categories along a continuum. I am reminded of deaf educator Patricia Scherer’s (1972, 553) statement during a heated debate at the 1972 AG Bell conference between educators and researchers advocating for total communication and those supporting oralism: “I like to present ‘total communication’ for deaf children as the English language on the hands, on the lips, supported by residual hearing, supported by everything that is needed to assure the communicator that he sends a clear message to the receiver. During this act of communication, the child is observed and he tells you how he needs to learn language. You must then respond to him in the channel or the way that is best suited to meet his particular and specific needs.” Later in the debate, Scherer concluded: “‘Total communication’ for me breaks down the barrier of deafness because it is simply . . . ‘the reaching out of one man’s soul to another’” (560). I see this statement in contrast with AVT practitioners’ above-discussed concerns with closed doorways to the brain.31 What about other doorways and paths?32

Recall Tanima’s approach to therapy, which involves doing “whatever works.” Similarly, consider comments made by a cochlear implant surgeon named Dr. Swarnad, who runs a series of early intervention programs, a school for deaf children up to six years of age, and a training program for mothers of deaf children throughout Maharashtra and Goa. Initially during our first meeting, he emphatically declared that his programs were “purely AVT. We only use AVT in our schools. Our children need to listen and speak.” However, a short while later in our conversation, he changed his tune. He said: “Actually, I am going to tell you something that you probably do not want to hear. There is a Sanskrit word and concept called sahishnuta. This word means ‘many paths.’ Indians, we pray to Krishna, we go to church, we go to the mosque, we do everything. The same we do for communication in our school. We use total communication, whatever works.” While Dr. Swarnad invoked a romanticized vision of Hindu forbearance and tolerance, I hold on to the importance of attuning to a child or person and being open to different senses and modalities. A focus on becoming auditory prevents such attunement and openness.

Ultimately, as Ochs, Solomon, and Sterponi (2005, 548) argue, “the habitus of a speech community may poorly serve the communicative development of the child, yet mature speakers may find themselves at a loss to improvise alternative strategies and persist with their default child-directed communicative practices.” In the next chapter, we move out of the clinic to early intervention and pedagogical spaces in which families (particularly mothers) want to do everything possible. They are, however, instructed by professionals to limit, rather than stretch, their communicative practices and to exclude different senses and modalities. They are discouraged from “improvis[ing] alternative strategies” or orienting through total communication. Yet they find ways to make communication happen. Despite instructions or their absence, mothers and children work through diverse signals and engage in signal labor (Sterne and Rodgers 2011). They intersense and orient toward each other in multisensory and multimodal ways, creating infrastructures of care.