Cochlear Implants in the Classroom
The Role of the Educational Audiologist
The cochlear implant has changed the ways that children with
significant hearing loss are educated. The large majority of
children with implants receive them as infants, and greater
numbers of children with implants are entering mainstream schools
at the beginning of their educational careers. Although
impressive in their accomplishments, these children still require
support to ensure their success. This support includes the
introduction of additional technologies and personnel who are
trained in working with hearing impaired children. The
educational audiologist (EA) is just one of several professionals
who play a major role in ensuring that the child with a cochlear
implant has every opportunity to achieve success.
In the school setting, the EA is the key individual for
assessing and monitoring the auditory abilities of a child with
hearing loss. The EA is knowledgeable about issues regarding
amplification and classroom acoustics, and he or she is a major
resource for other school professionals and parents regarding the
hearing needs of any given child. The EA's role includes
aspects of
assessment, rehabilitation, counseling, and advocacy.
Assessment
Assessing children, whether or not they are cochlear implant
candidates or recipients, is a major component of the school
audiologist's workload. With respect to children with
implants, involvement can begin at the preimplant level and
continue after implantation. Because the EA is responsible for
performing annual audiologic evaluations, he or she should have
knowledge of the criteria for implantation, as well as
familiarity with the implant process, device options, and
performance outcomes of children with implants. At the
postimplant stage, the EA can assist in monitoring the
child's performance to ensure maximal success by acting as
the main information gatherer among the other professionals and
the family. Providing input into the mapping process and
controlling the acoustic environment via frequency modulation
(FM) systems and classroom modifications are also within the
EA's purview.
Interaction at the Preimplant Interval
Criteria for cochlear implantation have changed substantially
over the years, and it is important for EAs to be aware of the
most current standards. School-age children with hearing loss can
be considered for cochlear implants despite demonstrating some
open set speech recognition with traditional amplification.
Scores of 40% on the Hearing-in-Noise Test sentences and/or 30%
on the Lexical Neighborhood Test or the Multisyllabic Lexical
Neighborhood Test are the upper limits of function at the
preoperative juncture. As the EA evaluates his or her caseload of
children each year, it is important that these percentages are
kept in mind so that parents can be fully informed about the
options for their child.
The process of implantation can be facilitated when the school
audiologist works collaboratively with the cochlear implant teams
that are in place at the medical centers performing the surgery.
The EA can disseminate information about cochlear implants in
general, the different centers that are available to the parents
(these may sometimes be limited due to insurance), the required
evaluations, and the time course of the process. Often,
individual cochlear implant centers that work closely with the
schools will have brochures about their services available at the
school. In addition, the EA should have manufacturer information
about the different implants in addition to Web sites, videos,
DVDs, and scheduled workshops about the device. It is important,
however, that the EA not recommend any particular device or
center. He or she can provide information to parents about
individual experiences with devices or facilities but should be
careful not to show bias toward one device or medical center.
The options that are available with the implant can become
very confusing for parents, and therefore the EA who is
knowledgeable about the different choices can assist families at
the early stages. The FM options, accessories, power choices, and
other consumer issues (e.g., warranty, reliability, and
manufacturer support) should be discussed to ensure that parents
can ask appropriate questions of the cochlear implant center
medical team. Finally, the EA should have some knowledge of
performance trends, especially with regard to the range of
performance and the factors that contribute to the
variability.
Interaction at the Postimplant Interval
Although the EA may have significant experience with hearing aid
and FM fittings, issues regarding mapping the cochlear implant
may be new or entirely unknown. It is, therefore, very important
for the EA to understand mapping at a basic level and be able to
provide school personnel with information that can contribute to
the mapping process. How often a child is to be mapped varies
from child to child and, in some cases, from center to center.
Assessing the suitability of a particular map requires a
comprehensive team approach that includes teachers, therapists,
and parents. The effects that mapping has on performance must be
understood from the larger picture of how the device works and
whether the child's performance is due to equipment issues or
innate physiological ones. Regardless, communication with the
mapping center is one of the most crucial aspects for ensuring
that the process is performed effectively. Mapping too often or
too infrequently can hurt performance. Likewise, the experience
of the mapping audiologist may affect outcomes either positively
or negatively.
Device benefit is related to physiological issues that cannot
be controlled at the time of implantation. The residual neural
elements in the cochlea that can be stimulated remain unknown, as
there is no method to identify them either pre- or
postimplantation. For children with long-term deafness or those
with anatomical constraints, electrical stimulation of the
cochlea may be seriously compromised, thereby limiting
performance. Additionally, there may also be central processing
or cognitive issues that the implant is unable to override.
Knowing these issues will enable the EA to help school personnel
and parents understand the individual differences observed in
children with implants.
Although aspects of neural survival and central processing are
beyond the control of EAs, the integrity of the external
equipment is well within their realm of expertise. For the
cochlear implant recipient to maximize input from the device, it
must be in good working order and be worn on a continuous basis.
Intermittencies in both the internal and external components of
the implant or generally poor working equipment will
substantially limit performance over time. EAs, therefore, should
be able to troubleshoot all equipment as well as train school
personnel (and in some cases the family and the child) in
checking for functionality. How the various external environments
(i.e., moisture, static, and noise) affect the implant should
also be understood so that proper precautions and procedures can
be put in place.
One of the key roles that EAs played in schools before the
increased use of cochlear implants was related to the use of FM
systems in the classrooms. This role has become even more
important as cochlear implant coupling options have become so
varied. For the EA to have the most impact on ensuring that FM
systems are functioning appropriately, he or she must be aware of
the subtle differences among the various devices, interfaces, and
FM systems. This is best accomplished by maintaining close
contact with the cochlear implant center and the FM manufacturers
so that the school is fully informed of the technological aspects
of the various systems.
Fitting FM systems on children who have little or no
experience with their cochlear implants may result in poor
outcomes because the children will be unable to provide feedback
if the sound is distorted or intermittent. Before fitting an FM
system, it is recommended that children have at least 3 to 6
months of cochlear implant experience and have adequate
communicative skills so that they can provide feedback about what
they hear. The EA should help to identify individuals who will be
responsible for monitoring the functioning of the FM system and
who will perform a daily listening check of the equipment. Input
from classroom teachers and speech-language pathologists who are
with the child on a more frequent basis should be valued to
determine the utility of the FM system for any individual
child.
To assess benefit for the child, the EA should be familiar
with the variety of performance measures that have been developed
for this population and know the age and language limitations
that contribute to this performance. In some cases, as cochlear
implant centers become overwhelmed with the large numbers of
children they follow, the EA can assist the center by collecting
valuable audiologic data to monitor performance. Standard
sound-field audiograms can assist in troubleshooting problems
with the external equipment. Although they do not provide
in-depth information about overall discrimination, audiograms can
provide insight into detection. When obtained at baseline, a
simple sound-field audiogram can often identify malfunctions of
microphones or processors.
One of the most important roles that the EA can play is that
of information gatherer, because he or she has access to
information from the classroom teacher, speech-language
pathologist, and teacher of the deaf. In this manner, the EA
takes on the role of case manager and provides valuable input to
the cochlear implant center on concerns regarding performance or
equipment.
Rehabilitation
Since audiologists are the most knowledgeable about acoustics
and auditory perceptual performance, they can provide valuable
insight to speech-language pathologists who interact with the
child with an implant. In addition, the EA can provide direct
services especially for those older children who require
listening training of key acoustic aspects of sound. The EA
should collaborate with the speech-language pathologist and
teacher of the deaf to ensure that therapeutic goals are
appropriate given the child's performance abilities with the
implant. This will prevent speech-language pathologists from
setting the standard too low or too high.
Rehabilitation training can take the form of being analytic or
synthetic in nature. For the older child (and in some cases, the
child who has been implanted for his or her entire educational
career), a combination of these two paradigms can be used. In
addition, training in speechreading through the use of continuous
discourse tracking will assist the student in learning strategies
for communication in and out of school. These kinds of approaches
can be presented in quiet and, for the more sophisticated
listener, in a background of competing noise. Newer technologies
such as MP3 players, Web sites with interactive programs, CDs,
and videos can be utilized to provide carryover assignments
outside the therapy environment. Regardless of the method
selected, the EA should be considered an additional member of the
rehabilitation team.
Counseling
As noted in the discussion of the preimplant and postimplant
interactions, the EA can take the lead in being the major
provider of information to parents as well as other school
professionals. As technology changes, it is the EA who will have
the responsibility of disseminating this information to the
appropriate professionals and to the child. In addition,
performance differences must be understood in the context of the
child and his or her individual abilities. Ultimately, children
with implants must be able to understand their own strengths and
weaknesses as they manage their deafness throughout their lives.
This allows them to take "ownership" of their deafness,
which leads to the final role that the EA plays in the education
of the child with a cochlear implant-advocacy.
Advocacy
Children with implants and their parents must learn the
options and services available and what is most appropriate for
the child. The role of advocate is played mostly by the parent,
especially during the child's early days of education;
however, the child must also learn to advocate for himself or
herself. As children learn to manage their own deafness, they
will understand their own capabilities. Assisting children with
this process is a role that the EA is maximally equipped to
perform.
It is clear that as children with implants progress through
the educational system, there will be many important
professionals with whom they will interact. The EA should be
considered a major contributor to the successful integration and
habilitation of these children.
Patricia M. Chute, EdD, CCC-A
Mercy College, Dobbs Ferry, NY
PChute@mercy.edu
About the Author
Dr. Patricia Chute is Professor and Interim Dean of the School
of Health and Natural Sciences at Mercy College in Dobbs Ferry,
New York. Prior to her appointment at the College, she was the
Director of the Cochlear Implant Center at Manhattan Eye, Ear and
Throat/Lenox Hill Hospital for more than 16 years. She is the
former Editor of the
Volta Review
and a member of the Scientific Trustees Board of the Deafness
Research Foundation. She has co-authored three books with her
colleague Mary Ellen Nevins:
The Parents' Guide to Cochlear Implants,
Children With Cochlear Implants in Educational Settings, and, most recently,
Professionals Working With Children With Cochlear
Implants. Both she and Mary Ellen also produced two videos for ASHA
dealing with various aspects of cochlear implant evaluation and
training. She has more than 40 publications to her credit and has
received funding from the Deafness Research Foundation, the
Lounsbery Foundation, and the Bodman Foundation. In 1995 she was
a speaker at the National Institute of Health Consensus
Conference on Children With Cochlear Implants.
This article first appeared in the Vol. 7, No. 6,
November/December 2008 issue of
Access Audiology
.