|Deborah Bervinchak, an auditory (re)habilitation therapist, works with 6-year-old Julie Yap at the Johns Hopkins Hospital in Baltimore, MD. They are working on a sound-object association task in which Julie matched pictures to sentences.
Cochlear implants (CIs) are one of the most significant technological achievements of the 20th century that have improved the outcomes for children with profound hearing loss—and greatly changed the ways professionals provide medical and educational care to these children. One key component in successful outcomes is a partnership between parents, educational professionals, and cochlear implant centers to work together to foster achievement of the communication goals set for the child by the child's parents. This article provides answers to questions that parents frequently ask CI centers about promoting improved communication and collaboration between the child's school and the implant center.
Why is the school-clinic partnership so important for a child with a cochlear implant?
Professionals in the field are routinely amazed and encouraged that many young children who receive CIs develop speech, language, and academic skills comparable to those of their peers with normal hearing (Geers, 2004). Such results are only possible, however, when post-operative care involves a comprehensive approach that emphasizes both medical and educational aspects of care. Cochlear implant centers are responsible for pre- and post-operative medical and audiological management, which includes determination of candidacy, medical evaluation, surgical intervention, post-operative audiological management (including programming the speech processor), post-operative evaluation of speech perception and speech and language skills, and (re)habilitation and family training/mentoring.
Educational settings must provide educational services to a diverse population of children who present with various etiologies and levels of hearing loss; utilize various modes of communication; present with wide-ranging (and sometimes changing) auditory needs or auditory goals; and utilize various forms of assistive technology. These factors have added great complexity to the provision of educational services. Not only do teachers need to be familiar with the care, use, and maintenance of the various technological devices available for children with hearing loss, but they also need to be aware of the influence that various factors will have on the child's educational success. In the case of children with cochlear implants, the rehabilitative procedures used with the child should support the goals set forth by the parent regarding the child's development of spoken language skills.
Although professionals in the CI center and the child's educational setting serve different roles, good communication between these two groups can greatly enhance the outcomes achieved by the child with a CI. The implant center can share information such as results of audiometric testing, information about the specific device(s) used by the child, troubleshooting and maintenance tips, and the results of speech perception and speech and language evaluations; the educational setting can provide information regarding the child's academic performance and any problems regarding ability to hear and function in the classroom.
What services do children with cochlear implants typically need at school?
Most children with CIs receive some type of special education service at school. The most frequently utilized services reported by parents included speech-language pathology services (75%), use of FM systems (65%), and deaf education services (54%), according to a 2003 survey by Sorkin and Zwolan. Other services included individual or small-group instructional support, use of an interpreter, audiology services, captioning, listening therapy, and acoustical improvements to the classroom. In the 2003 survey, 27% of children with CIs used sign language interpreters. It is anticipated that this number will drop, however, as more children receive their implants at younger ages and utilize spoken language as the primary communication modality. The survey also showed that 66% of children ages 7 to 13 were using spoken language. Further, the majority of children in this age group—64%—were attending public or private mainstream schools.
In the Sorkin and Zwolan survey, many of the children began their educations in a school or pre-school program designed for children with hearing loss, and later moved to a mainstream school. Today, many children implanted at a young age begin their pre-school experience in the mainstream. Many parents feel the mainstream experience provides many advantages, such as the language role models offered by typically hearing children and the child's enhanced preparation for the larger world. It is important to note, however, that placement in the mainstream does not eliminate the need for support services, as the 2003 survey demonstrates.
Although the child with a cochlear implant will often require special accommodations to improve speech recognition in the classroom (i.e., use of an FM system or acoustical modifications), mainstream placement can positively facilitate greater challenge for the implant recipient who is expected to perform at the same level as normal-hearing peers. It is essential, however, that the child's progress be monitored by both the school and the CI center to determine if the child's placement is socially and academically appropriate.
Regardless of the child's placement, a child with a CI involves additional responsibilities for the classroom teacher, who must monitor the use and proper functioning of the device and FM system. Some school districts employ educational audiologists, who often serve as the school's "expert" on CIs, hearing aids, and FM technology. However, our research indicated that only 26% of children with CIs received audiology services at school. Without such personnel, educators must fill the role of "specialist," but often have few opportunities to receive much-needed training. In this situation, the school can obtain information about the child's device from the CI center, implant manufacturer, or parents. Importantly, families should be trained to serve as the primary advocate for the child and to be a source of information for teachers. Parents can set up formal meetings to share informational pamphlets and videos, demonstrate how to troubleshoot the device, and provide troubleshooting equipment to the school.
What happens when the parents, the implant center, and the school disagree about what is appropriate for the child?
When so many professionals are involved in the child's care, it is not unusual to find a difference of opinion regarding what is appropriate for the pediatric CI recipient. This situation can be difficult, if not contentious—although this need not be the case.
In the University of Michigan Cochlear Implant Program, the parent is viewed as the key member of the team responsible for making decisions about implantation, preferred communication methodology, and educational setting. Because the cochlear implant is a tool for the development of spoken language, one of the first steps in the implant process is a discussion with the family regarding the need to set goals for the child's development of spoken language. In order to assist with development of such goals, families are provided with published information regarding factors that are known to affect outcomes with a cochlear implant (for example, age at implantation and communication methodology). Rehabilitative procedures used at the center and educational recommendations made by the CI program are centered around the goals of the family. Occasionally, recommendations made to the family by the CI center and the educational setting will differ greatly, forcing parents to choose the recommendations of one professional and go against the recommendations of another. This is often difficult as both groups of professionals work closely with the child and his/her family. When this occurs, we encourage parents to seek a second or third opinion about the educational setting and its ability to help the child meet his/her Individualized Education Program goals. Regardless of the outcome, professionals need to provide evidence-based information that will help parents make educated and informed choices for the child. Importantly, we must respect and support the decisions made by the even if it differs from our professional recommendation.