In late 1990 the U.S. Food and Drug Administration (FDA) approved the surgical placement of multi-channel cochlear implants (CIs) for children with prelingual deafness. At the University of Iowa Hospitals and Clinics, the first cohort of children who received CIs ranged in age from 3 to 18 years and were implanted between the late 1980s and 1999. Gradually over the past two decades we have learned that children who are deaf and who receive CIs achieve higher scores on tests of speech perception and production than their peers who use hearing aids (Fryauf-Bertschy, Tyler, Kelsay, & Gantz, 1997; Peng, Spencer, & Tomblin, 2004).
Subsequent studies began tracking the development of language and reading skills and found similar results (Spencer, Barker, & Tomblin, 2003; Eisenberg, Fink, & Niparko, 2006). Furthermore, investigations began to indicate that the younger the child was at implantation, the better the speech and language outcomes (Tomblin, Barker, Spencer, Zhang, & Gantz 2005).
Implications of Early Identification
The combined efforts of audiologists, speech-language pathologists, physicians, and government agencies have contributed to the impressive increase in the successful identification of infants who have hearing loss in the United States. The American Academy of Pediatrics position statement of 2007 states as a goal that all infants should be screened for hearing loss before leaving the birthing hospital or by 1 month of age (JCIH, 2007). The infants who fail the screening are to receive follow-up audiologic testing by 3 months of age, and infants who are confirmed with hearing loss should begin to receive intervention before 6 months of age. With these intervention targets, and the FDA's 2000 approval of implantation in children as young as 12 months of age, more centers began implanting children very close to their first birthdays. Figure 1 [PDF] shows the decrease in the average age of implantation at the University of Iowa Hospitals and Clinics from 1987 to 2007 and notes an average age at implantation of 2.3 years in 2007.
This trend means that SLPs have begun or will soon begin to see infants as young as 3 months old who are in the process of a hearing aid trial, or infants as young as 1 year of age who have received one or even two cochlear implants. This trend in turn increases the need for opportunities for early intervention specialists to network and to share information about treatment practices and outcomes.
SLPs are in a key position to ensure that adequate follow-up and diagnosis for infants who fail the hearing screening take place, and should be familiar with some basic practice suggestions. If you are in the role of a community provider of speech-language services, ask the parents to add you to the information release paperwork so that you can be part of the family's early intervention team and assist with the follow-up process and information dissemination.
Initial Cinical Issues
As a member of the team providing early intervention services, an SLP will need to address at least three immediate issues with the child's family: device compliance, communication philosophy, and genetic testing.
After an infant has been evaluated and a severe-to-profound bilateral hearing loss is diagnosed, the child in most cases will be fit with hearing aids for trial. Whether the child is wearing hearing aids or receives a CI, you as the SLP working with the child can now become an intrinsic part of the hearing aid trial and/or the initial fitting and mapping process for the CI.
An important goal at this point would be to ensure the parents understand the importance of device compliance. The following points may serve as objectives toward meeting this goal:
- Discuss the input that the hearing aids or the CIs provide and the importance of assuring the child wears the device consistently.
- Emphasize that an early goal will be to facilitate the child's development of sound awareness and sound discrimination.
- Teach the parents to distract the child if he or she reaches to pull out the device as a means of interrupting the behavior.
- Teach the parents to use praise once the child stops trying to pull out the device.
- Ask parents to report how many hours a day the child wears the device.
Ask the parents to track how often they need to change batteries. (This tracking can give you an idea of whether battery life corroborates with reported amount of use.)
- If parents are not keeping the device on the infant, investigate the reasons: Does the hearing aid have feedback? Is the earmold too small? Does the external coil of the CI keep falling off? (Troubleshoot to evaluate whether cord length is correct or magnet strength is appropriate.) This valuable information will help members of the child's team who manage the device to make proper modifications.
Explore with the parents whether they are aware of their choices for communication modality or philosophy for their child and whether they have thought about which philosophy to adopt. If the infant or toddler is going to receive (or already has) a hearing aid or a CI, this choice indicates the parents' preference for teaching the child to use voice and listening for communication, but it does not rule out using sign language.
Among the initial cohort of children who received a CI at the University of Iowa (those implanted before the year 2000), communication philosophies varied. Approximately 20% of the children were in programs that used American Sign Language and did not emphasize oral language development; 75% of the children were in programs that used a total communication (TC) approach (use of signed English and development of speech and listening skills). About 5% of the children were in programs that embraced an oral communication approach.
In the second cohort (those children implanted after the year 2000), there is a much stronger tendency for the children to be taught using a TC philosophy. Some families indicate they plan to transition to an oral communication approach as the children grow older. Fewer than 5% of the patients were in ASL-only programs.
Discuss with parents the possibility of genetic testing. Many cochlear implant centers will have addressed genetic testing, but not all. With early identification of severe-to-profound hearing loss, both parents and professionals should consider the presence of any additional health conditions and examine whether the cause of the hearing loss is genetic. This information can be very helpful in planning treatment programming and may influence overall life choices for the family.
SLPs who work with infants and their parents—and who may be the health and education professionals who have the greatest interaction with the family—may be in a unique position to support parents who are just beginning to cope with their child's hearing loss.
Grief and Acceptance
Early identification of hearing loss means that parents face many important and stressful decisions soon after the birth of their child. For example, they must begin making decisions pertaining to communication methods and philosophy, a possible hearing aid trial, and even subsequent surgery for the CI. For these parents, the process of bonding with the child and the subsequent progression through the stages of grief to achieve acceptance can be interrupted or incomplete as many decisions are telescoped into a very short time period.
Local service providers are again in a position to assess and perhaps assist the parents on their road to acceptance. Sometimes failure to abide by the treatment plan and problems with device compliance can be symptoms of the parents' denial. Similarly, a history of arriving late to or missing appointments can also be evidence of denial or even anger with the situation.
For first-time parents, the challenge of adjusting to parenthood is increased by coping with the additional routines of a child with special needs. These situations will call upon your counseling and listening skills. Part of your sessions may be devoted to spending time addressing these issues and validating the feelings and issues the parents will need to discuss. Parent support groups can be an excellent way of facilitating the families through the process (see "Family Resources" sidebar).
Successful Communication Strategies and Behavioral Limits
Communication professionals also can guide the parents by helping them to learn effective and positive communication strategies. Parents are the infant's most readily available communication partner, and as the infant grows older, parents' ability to communicate will become a vital part of the parent-child relationship.
Parents who feel confident in their ability to interact will have an advantage as the infant becomes a toddler and the parents need to use language to set behavioral limits. Parents can use language to teach their child that tantrum behavior will not produce the child's desired outcome. Clinicians can encourage, support, and teach the parents to set limits by modeling how to do so.
Showing parents that the child can learn to respond to directions such as "you cannot climb," "crying will not work," and "No, I will wait" will give the parents confidence to set limits and will help with the development of overall compliant behavior.
Treatment for Infants and Toddlers
Early interventionists play major roles in the mapping of CIs, as well as in the development of the infant's listening goals and speech/language goals.
Audiologists who work with the pediatric implant population are extremely well-trained in the science and art of reading behavioral responses of infants and toddlers. Even so, the process of "mapping"—setting the electrical thresholds of each implant channel—of young patients is not easy, quick, or without error. As an SLP, you should feel comfortable establishing a relationship with your clients' audiologists; your input will be welcomed, just as their information will help you in your treatment goals.
You can help with the initial mapping appointment by helping to reinforce the instructions provided by the implant center and encouraging the family to read the literature, such as the user manual, the implant center may have provided. Most centers will require the families to make several appointments during the first post-implantation year. Typically, the first appointment takes place three to four weeks after surgery and lasts about two hours. Subsequent appointments take place two weeks later, then at about one month post-activation and monthly for the first half of the year. During the second half of the first year, appointments gradually become less frequent. During the second year and onward, appointments are typically at six-month intervals until the child attends school (see sidebar for cochlear implant manufacturer Web sites for teachers).
Initial Listening Goals
For infants and young toddlers, part of the session may occur when the child is happily sitting in a high chair or a stationary activity center. This arrangement will help to contain children who are very active; it will maximize their attention and give you a chance for some "formal" treatment.
Initial treatment goals may include the following:
- The child will consistently respond to auditory stimuli.
- Use block-dropping type activities, puzzles, stickers, etc.
- Begin with auditory/visual stimuli until the child's responses are consistent.
- Vary stimuli from vowels, consonant/vowels, words.
- Use auditory-only stimuli when the child's responses are consistent.
- The child will discriminate between contrasting sounds.
- Use closed-set items, pictures.
- Begin auditory/visual stimuli until responses are consistent.
- Use large contrasts between stimuli (hop, hop, hop for a rabbit vs. ahhhhh for airplane; cup vs. diaper bag).
Examples of initial speech and language goals may include the following:
The child will produce canonical babble. Most infants who are deaf and at least 12 months of age will be close to producing pre-canonical babble or approximation of consonant/vowel combinations.
- Consistently produce vowels, vowel prolongations.
- Produce visual consonants /b/ /p/ /m/, followed by /t/, /d/, /n/.
- Produce consonant/vowel combinations and replications.
- Use advanced forms, such as dipthongs.
- The child will label and name objects and will make requests.
- Use a standard set of toys and routines to label items.
- Use short, one- to three-word utterances (ball-throw ball; cow-moo-cow; puppy-puppy bark; bubbles-blow bubbles-bubbles, more bubbles).
Working with families and their infants or toddlers who are progressing through the process of getting one or two cochlear implants for their child is an exciting and rewarding experience. If this is your first experience as a professional, you'll become a part of the team and have the opportunity to collaborate with those who have more experience. Your observations, input, and support will be a valuable resource.