Approximately 738,000 persons have severe to profound hearing impairments in the United States and increasing numbers are seeking cochlear implantation, including adults with long-term and prelinguistic hearing loss. However, variable outcomes in relation to cochlear implant performance have been reported in these populations (Schramm, Fitzpatrick, & Seguin, 2002; Waltzman, Roland, & Cohen, 2002). Clinically, these variable outcomes can be disappointing for clients. Therefore, adults with prelinguistic hearing loss could be considered borderline for cochlear implantation and may be more likely to benefit from more comprehensive pre-implant counseling.

Multidisciplinary Team Assessment

Chute (2004) suggested that individuals should be "maximally informed" prior to implantation and seek information from a variety of sources. Chute cautioned that single source information can be influenced by personal bias. This critical concept has ethical implications for the borderline cochlear implant candidate population.

One way for such candidates to receive information from multiple sources is through consultation with a multidisciplinary team. The team should include an otolaryngologist, audiologist, speech- language pathologist, vocational rehabilitation (VR) counselor, and psychologist. Provision of these services is time consuming. Clients need and expect ongoing mapping and service for maintenance of their implants, yet face an insufficient number of audiologists trained to work with cochlear implants (Parisier, 2003).

In this situation, audiologists can turn to other professionals to assist in providing adequate counseling for candidates with prelingual impairments. VR counselors can provide "considerable supportive effects" for individuals with hearing loss (Backenroth & Ahlner, 1997) and could enhance the candidates' understanding about implantation outcomes and how it could impact their functional and vocational potential.

VR counselors can discuss qualitative issues related to implantation with their clients and provide information that complements the diagnostic, medical, and technical information that candidates receive from implant centers. VR counselors can also assist in identifying resources where individuals may obtain post-operative treatment. SLPs are uniquely qualified to evaluate overall communication function, suggest appropriate goals, and develop a treatment plan. Audiologists and otolaryngologists provide extensive pre-operative information ranging from device options to surgical procedures. However, the decision-making process must include input from multiple sources so that candidates can evaluate the information in relation to their own personal life course.

Life Course Theory

The Life Course Theory (Elder, 1998) is widely used in sociological and psychological studies and provides a framework for understanding the impact of events over a lifetime. It attempts to explain the diversity of outcomes in lives when consideration is given for cultural and social contexts, as well as the history and timing of events in a person's life. The five premises at the core of Life Course Theory are summarized in the table on page 19. These principles highlight the importance of individual choices and decisions that are made during a lifetime that impact the trajectory of a person's life course. The theory further explains that human beings must be considered within the context of their personal relationships and cultural settings. The people with whom they share their personal and community life can have a major influence on them. Historical events can greatly impact the life course of a cohort group of individuals, and the timing of those events in terms of when they occur in a person's life will impact the outcome as well.

Life Course Theory may provide a useful format for VR counselors and audiologists to counsel their borderline implant candidates. The premises of the theory "merge" with several issues related to the decision-making process involved with cochlear implants. The first premise correlates with lifelong human development and states that multiple trajectory paths are possible.

Implant candidates need to be counseled that choosing implantation could result in either positive and/or negative outcomes that may greatly impact an individual's ability to communicate, work, and participate in recreational activities throughout daily life. Candidates should be cautioned to devote adequate time to making a decision regarding implantation since the procedure is irreversible. If they choose implantation, borderline candidates should be aware that extensive rehabilitation may be necessary post-operatively to derive maximum benefit from an implant.

In-depth discussion with adults should focus on the relationship between the onset and duration of a hearing loss and how that impacts the speech perception trajectory. For example, audiologists and SLPs can highlight the difference between awareness of speech vs. the understanding of speech prior to implantation. Implant recipients may be severely disappointed with the derived outcomes if this critical difference is not adequately explained. Most audiologists make every effort to explain possible outcomes; however, those explanations often are ignored in light of patient expectations.

The trajectory model used in life course studies could help illustrate this issue. Adults who are deaf derive benefit from visual illustration of complicated issues. The trajectory model illustrates the relationship between duration of deafness and potential speech understanding capability. A hypothetical model in Figure 1 (PDF format) that illustrates both positive and negative outcomes would provide a more thorough explanation of the variability in performance that is observed in this population. This model may help individuals understand the prognosis based on their own personal history. VR counselors might be able to use a similar trajectory model to map the expected vocational, educational, or social changes that the individual is likely to encounter based on speech recognition projections. Candidates and their families need to visualize how a life course could be impacted both positively and negatively in terms of their current educational, social, and vocational ability.