Cochlear Implants for Children

Roles and Responsibilities of Audiologists

Audiologists play a primary role in a collaborative interdisciplinary/interprofessional team in the assessment and (re)habilitation of children with CIs. Professional roles and activities in audiology include clinical and educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2004).

Appropriate roles and responsibilities for audiologists include the following:

  • Maintaining general knowledge of anatomy, physiology, and pathophysiology of the auditory system and the effects that cochlear and neural anomalies may have on outcomes with a CI.
  • Remaining current on information related to hearing aid technology, hearing assistive technology systems (HATS), and other applicable technology.
  • Serving as a member/coordinator of a collaborative, interdisciplinary/interprofessional CI team.
  • Coordinating and conducting a comprehensive, culturally and linguistically appropriate assessment for determination of CI candidacy as part of a CI team.
  • Gathering formal and informal information on functional listening behaviors that may influence candidacy decisions.
  • Facilitating discussions of candidacy determination and outcome expectations for cochlear implantation with the CI team.
  • Providing referrals to other professionals to facilitate access to comprehensive services.
  • Developing a plan of care with input from the child, family/caregivers, and appropriate professionals.
  • Consulting with the surgeon regarding audiometric qualifications that may affect the choice of electrode array.
  • Providing intraoperative monitoring/electrophysiological testing during cochlear implantation.
  • Using contemporary behavioral and/or objective measures to set the upper and lower stimulation levels and device parameters that will be used in the sound processor program.
  • Maintaining general knowledge on cochlear malformations, cochlear ossification, and the effect that they will have on programming parameters and outcomes.
  • Coordinating with other professionals to develop an appropriate and comprehensive aural (re)habilitation plan.
  • Counseling children and their families about the proper care and use of the sound processor and its accessories.
  • Counseling children with CIs and their families regarding communication-related issues and rights to services.
  • Inspecting the surgical site and alerting the patient's family/caregivers and the surgeon if there is a possible need for medical intervention.
  • Monitoring device use (i.e., checking data logging) to support optimal outcomes.
  • Inspecting external equipment for proper function.
  • Validating hearing technology use in a variety of communicative settings through interprofessional communication.
  • Consulting with the device manufacturer if failure of the internal device is suspected.
  • Evaluating the child's detection skills with the device for auditory access to soft speech.
  • Assessing speech recognition, auditory detection, and functional listening with measures appropriate for the child.
  • Educating other professionals about CIs, assistive devices, CI recipients, and the role of audiologists on the CI team.
  • Advocating for children with CIs and their families at the local, state, and national levels.
  • Managing hearing aid technology, HATS, and other applicable technology.
  • Remaining informed of research in the area of cochlear implantation, availability of products, advances in implant technology, U.S. Food and Drug Administration (FDA) approval of new devices, implant reliability, and implant recalls.

As indicated in the Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so. Roles may vary depending on patient factors and specifics of the CI team.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists play a central role in a collaborative interdisciplinary/interprofessional team in the assessment and (re)habilitation of children with CIs. Professional roles and activities in speech-language pathology include clinical and educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).

Appropriate roles and responsibilities for speech-language pathologists include the following:

  • Maintaining general knowledge of anatomy, physiology, and pathophysiology of the auditory system and the effects of hearing loss on communication development.
  • Serving as a member of a collaborative, interdisciplinary/interprofessional CI team.
  • Providing a direct and comprehensive, culturally and linguistically appropriate, evaluation of a child's speech, language, and communication skills.
  • Establishing a baseline for the child's speech and language skills prior to intervention or cochlear implantation.
  • Gathering formal and informal information on functional listening behaviors that may influence candidacy decisions.
  • Participating in discussions of candidacy determination and outcome expectations for cochlear implantation as part of the CI team.
  • Referring to other professionals to facilitate access to comprehensive services.
  • Coordinating with other professionals to develop an appropriate and comprehensive aural (re)habilitation plan.
  • Providing direct (re)habilitation services in coordination with other professionals involved in the (re)habilitation process.
  • Developing and using ongoing progress data and functional outcome measures as appropriate.
  • Assessing the child's speech, language, auditory, and communication skills on an ongoing basis and in a variety of settings after cochlear implantation and sharing results with the CI team.
  • Alerting members of the CI team if a child is not making expected progress with the device so potential causes may be investigated.
  • Counseling the child and family/caregivers on modes of communication and expectations regarding communication development following cochlear implantation.
  • Educating other professionals about CIs, assistive devices, CI recipients, and the role of speech-language pathologists on the CI team.
  • Advocating for individuals with CIs and their families at the local, state, and national levels.
  • Remaining informed of research in the area of cochlear implantation.

As indicated in the Code of Ethics (ASHA, 2016a), speech-language pathologists who serve this population should be specifically educated and appropriately trained to do so. Roles may vary depending on patient factors and specifics of the CI team.

Assessment

See the Assessment and Cochlear Implant section of the following evidence maps: Hearing Loss (Newborn) Evidence Map, Hearing Loss (Early Childhood) Evidence Map, and Hearing Loss (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.   

A comprehensive assessment for cochlear implantation in children includes several components. Candidacy determination, outcome expectations, device selection, and consideration of insurance coverage or other funding sources are all part of the assessment process. The collaborative CI team develops a coordinated assessment plan for cochlear implantation that requires input from several disciplines as well as from the family/caregivers (including the child, as appropriate). Multiple assessments are completed. Results from each team member's assessment contribute to candidacy determination and outcome expectations. The team will provide an explanation of test results and realistic expectations to the family/caregivers (including the child, as appropriate) to assist in informed decision making regarding cochlear implantation.

See ASHA's resource on Interprofessional Education/Interprofessional Practice (IPE/IPP).

Candidacy

Candidacy criteria for cochlear implantation have evolved over time. Early identification of hearing loss, through universal newborn hearing screening in the United States, is a factor contributing to children now being implanted by 12 months of age (see the Newborn Hearing Screening Practice Portal page). CI candidates may include very young children with prelingual deafness, children who are no longer benefitting from hearing aids, or children who unexpectedly lose their hearing in one or both ears.

Determining candidacy is a complex and variable process. During the candidacy process, beyond the assessment of auditory function, consideration is given to medical status, potential communication benefit, and presence of support systems and services. The result of the candidacy process is determination of a child's candidacy for cochlear implantation.

Information is typically collected from the following professionals and sources.

Case History

A comprehensive case history for a pediatric cochlear implantation candidate may include

  • age of child;
  • onset and duration of deafness, whether prelingual or postlingual;
  • medical history (including co-existing disabilities and prenatal/birth history);
  • hearing health history (including previous amplification);
  • psychological history;
  • family history of hearing loss (including results of genetic testing, as available);
  • information and results from other professionals, as available;
  • radiologic results (CT, MRI), as available;
  • child's current educational placement, support services, and modes/strategies for communication; and
  • information regarding family/caregiver expectations and availability for support.

For more information regarding gathering a case history, see the Cultural Competence Practice Portal page.

Otology

An otologist may provide information on

  • viability of the seventh and eighth nerves  based on radiologic findings;
  • interpretation of neurological and vestibular screening;
  • cochlea size, length, and patency;
  • various CI devices based on patient factors and device availability; and
  • unilateral versus bilateral device recommendation.
Medical/Primary Care

A primary care physician may provide information on

  • general health status;
  • vaccination status (e.g., meningitis);
  • consideration for other health issues; and
  • information on stability for surgery.
Audiology

The audiologic assessment may vary depending on the age and language/cognitive abilities of the child. Ideally, a comprehensive audiologic assessment is performed. Refer to the Assessment section of the Permanent Childhood Hearing Loss Practice Portal page for more information.

An audiologist may provide information on the following:

  • Quantification of the candidate's preoperative hearing and communicative status, including residual hearing.
  • Appropriateness of hearing aids and/or recommendation of more appropriate hearing aids.
  • Results of a hearing aid trial and patient compliance with use of hearing aids.
  • Parent/caregiver responses to scales or questionnaires regarding the child's auditory skill development.
  • Speech/auditory reception testing, as appropriate per child's age, development, and language skills.
  • Vestibular testing, as indicated.
  • Realistic expectations for performance outcomes.
  • Comparison of current status to expected outcomes with CI.
  • Impact of case complexities, such as
    • abnormal auditory nerve;
    • auditory neuropathy spectrum disorder;
    • autism spectrum disorder;
    • balance disorder;
    • cochlear ossification;
    • cognitive, emotional, and behavioral disorders;
    • disabilities in addition to the hearing loss;
    • family support and home environment;
    • hearing loss associated with syndromes;
    • malformed cochlea;
    • mobility/dexterity considerations;
    • unilateral hearing loss; and
    • visual impairment.
  • Unilateral versus bilateral device recommendation.
  • Various CI devices based on patient factors and device availability.
  • Timeline for surgery, programming of the processor, and aural (re)habilitation.
  • Treatment options, including aural (re)habilitation.
Speech-Language Pathology

A speech-language pathologist may provide information on

  • pre-CI communication skills, including expressive and receptive language, articulation, intelligibility, and auditory comprehension;
  • pre-CI literacy skills;
  • play skills (nonsymbolic and symbolic);
  • executive function behaviors, such as attention and self-regulation;
  • disabilities in addition to the hearing loss;
  • current modes/strategies for communication;
  • functional listening skills observed or reported by the parents/caregivers;
  • prognosis for the development or advancement of verbal expressive language, auditory receptive language, and speech production; and
  • treatment options, including aural (re)habilitation.
Psychology

A psychologist may provide information on

  • nonverbal IQ;
  • behavior;
  • family structure and support;
  • expectations of parents/caregivers and child (if age appropriate); and
  • other psychological or developmental factors that may impact success with cochlear implantation.
Educational/Social Support

An educator and/or social worker may provide information on

  • support services available pre- and post-implant;
  • educational placement and progress; and
  • available resources.
Child and Family/Caregivers

The child and family/caregivers may provide information on

  • current concerns for the child's listening, communication, and/or academic skills;
  • long-term goals, desired outcomes, and the family's/caregiver's vision they hold for their child;
  • motivation and commitment to follow-up and therapy;
  • selected communication mode and the CI's role in the child's development of language; and
  • compliance with recommendations.

Selection

Selection of a CI involves consideration of medical factors, center offerings, family/caregiver input, and comparison of the available device components and features. The FDA approves CIs for use and makes recommendations regarding age and degree of hearing loss. It is not uncommon for infants and children to undergo CI surgery “off-label,” either for an approved study or if there are concerns of rapidly progressive hearing loss, such as cochlear ossification from meningitis. The different processor styles from which candidates/families can choose include behind-the-ear, off-the-ear, and single-unit, depending on the particular device manufacturer. Whichever CI manufacturer's device is selected, the implant recipient will be able to use only that manufacturer's external equipment. Advancement in CI technology has resulted in improved features, sound quality, and improved hearing in noise. Examples of improvements include directional microphones, advanced signal processing to reduce the effects of background noise, FM/DM system compatibility, telephone coils that enable clearer telephone communication and connectivity to loop systems in public venues, connectivity to Bluetooth and streaming devices, enhanced music quality, and water-resistant processors that can be used in water environments with a protective cover.

Reimbursement

Health insurance coverage for CI services has expanded in recent years. Many state Medicaid programs offer some coverage through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) funding, and supplemental funds are often available through vocational rehabilitation, Maternal and Child Health Services block grants, and other combined federal/state programs. Due to the acceptance of CIs as a standard of care, many private insurance payers cover all or part of the CI surgery and postsurgical services. Insurance coverage can vary in regard to factors such as bilateral versus unilateral cochlear implantation, simultaneous or sequential bilateral implant surgeries, and clinical investigations approved by private payers.

For more information regarding CI coverage, visit ASHA's Billing and Reimbursement resource. 

Treatment

See the Treatment and Cochlear Implant section of the following evidence maps for pertinent scientific evidence, expert opinion, and client/caregiver perspective: Hearing Loss (Newborn) Evidence Map, Hearing Loss (Early Childhood) Evidence Map, and Hearing Loss (School-Age) Evidence Map.

Because the first 3 years of life are a critical period for speech and language development, cochlear implantation is recommended at an early age, if possible. Studies have also shown that longer inter-implant intervals for bilateral implantation result in discrepancy in central processing and subsequently have negative effects on receptive and expressive language development (López-Torrijo, Mengual-Andrés, & Estellés-Ferrer, 2015). Each child's needs are considered individually, and all care is patient centered. It is crucial for the CI team to work interprofessionally to determine the best treatment options for each child. In addition, the team should educate and counsel a confirmed recipient and family/caregivers about device options, surgical implantation procedures, postsurgical care, audiologic management of the device(s), future processor upgrade, aural (re)habilitation, outcome expectations, and family/caregiver involvement.

See ASHA's resource on Interprofessional Education/Interprofessional Practice (IPE/IPP).

Surgery

Prior to surgery, the surgeon will discuss the procedure as well as possible risks and complications with the family/caregivers and the child, as appropriate. The surgical procedure involves inserting the electrode array into the scala tympani in a secure manner while attempting to avoid trauma and damage to the surrounding tissue or damage to the device. During the surgery, the radiologist may perform intraoperative radiographic imaging, and the audiologist may conduct electrophysiologic testing.

Intraoperative radiographic imaging is considered the gold standard for monitoring correct electrode placement during CI surgery. It may include plain film X-ray, 3D rotational tomography X-ray, CT scanning, and/or fluoroscopy. Intraoperative fluoroscopy may be used when implanting an abnormally shaped cochlea to confirm proper electrode placement.

The purpose of electrophysiologic measures is to verify whether the device is working properly and whether electrodes are placed properly. The measures also determine the ear's responsiveness to electric stimulation and assess cochlear trauma and residual hearing during electrode insertion. During such testing, the seventh nerve, eighth nerve, or stapedial reflex may be activated electrically through the implanted electrodes, and the response is seen via physical or telemetric observation. Tests done during surgery may include electrode impedance (EI), evoked compound action potential (ECAP), spread of excitation (SoE), and electrically evoked stapedial reflex thresholds (ESRTs).

  • EI measurements help determine if electrode circuits are functioning within normal limits. Test results do not determine whether the electrode array is properly placed.
  • ECAP measurements determine functionality of the eighth nerve to electric stimulation. Thresholds to stimulation may be used intraoperatively and postoperatively.
  • SoE measurements determine the decay of a signal between electrodes. They also establish whether the signal that stimulates one electrode predictably masks the neural response to the stimulation from a neighboring electrode. The purpose of SoE measurement is typically to look for tip foldover in the electrode array that can occur during insertion.
  • ESRT measurements are more rarely done during surgery and may be visualized by direct observation or via measurement of immittance. This threshold value is highly correlated with upper stimulation levels for CI recipients, serving as a target for postsurgical programming of the device.

As surgical techniques improve, intraoperative monitoring will likely be more useful in minimizing cochlear trauma and preserving residual hearing. Universal clinical practice guidelines are not available for intraoperative monitoring. A protocol may be established by each clinic/surgeon.

Bilateral Cochlear Implants

Bilateral implantation may result in better sound localization, enhanced understanding of speech in noisy environments, and improved language development (Brown & Balkany, 2007; Lammers, van der Heijden, Pourier, & Grolman, 2014). The decisions regarding bilateral implantation are based on (a) evaluation of each ear separately as well as simultaneously, (b) determination that each ear meets criteria for implantation, (c) potential benefits to the child, and (d) insurance coverage for a second implant. Due to neuroplasticity and the critical periods of auditory, speech, and language development in young children, it may be more beneficial to perform simultaneous or short-interval sequential implantation in this population (López-Torrijo et al., 2015).

Sound Processor Programming

The audiologist will schedule several programming sessions with the child and family/caregivers across a time span of several months. During the programming, the audiologist will determine thresholds and upper comfort levels on the electrodes. Sound coding strategy and parameters such as optimal electrode selection and grounding, rate of stimulation, and pre- and post-sound processing features are considered. The process is individualized based on factors such as age, cognitive skills, and duration of hearing loss.

Generally, programming a CI may be divided into four phases: preprogramming, intraoperative testing, initial stimulation, and follow-up.

  • Preprogramming is used to prepare the patient for postoperative stimulation. The audiologist may fit the patient with powerful hearing aids and/or an FM device. During this phase, an emphasis is placed on counseling.
  • The goals and benefits of intraoperative testing are explained in the surgery section of this page. Some clinics are able to perform intraoperative testing remotely.
  • Initial stimulation takes place shortly after the surgical wound is healed. Programming sessions may take place on consecutive days, and for multiple hours per day. Extensive counseling and education continues during this phase.
  • Comprehensive follow-up with an audiologist is critical, especially during the first year after implantation.

When behavioral feedback is limited, the audiologist may use objective measures as programming guidance. The most common objective measures are similar to those obtained during surgery—EI, ECAP, and ESRT (detailed in the Surgery section).

During the initial programming session, the audiologist is looking to confirm that the CI is working properly and to validate surgical procedure results. As in surgery, EI is used to measure the integrity of the electrodes in the device. Electrodes functioning with abnormal EI may result in poor sound quality, pitch confusion, and overall reduced performance of the CI. ECAP responses determine the collective response of the auditory nerve to device stimulation. ESRT values often give the audiologist information about uncomfortable loudness levels. ESRTs are more challenging to obtain than ECAPs. As in populations with normal hearing, reliable measurement of an electrically evoked stapedial reflex requires a healthy middle ear. The patient must sit still and silent to maintain an acoustic seal for the measurement probe and to prevent artifacts from movement and/or vocalization from obscuring the reflex response.

Cochlear Implant Orientation

Care and maintenance of a CI involves both postsurgical care and long-term care. After surgery, detailed postsurgical instructions are given to the child and family/caregivers. The most important factor is to keep the area clean. Follow-up visits are necessary to safeguard against infection. Once the surgical site has healed, the sound processor is put in place.

Education regarding long-term use, care, and maintenance prepares the child and family/caregivers to do the following:

  • Keep the device dry and moisture-free.  
  • Dry, clean, and inspect the device for moisture and debris after daily use.
  • Store device in a container with a desiccant, particularly after exposure to water or moisture.
  • Remove device nightly.
  • Change microphone filters as recommended by the manufacturer.
  • Use a waterproof processor cover, as appropriate.
  • Change and/or charge batteries, as needed.
  • Keep skin under the device clean, and check for irritation and/or infection.
  • Use protective headgear when engaging in sports or activities that may put the user at risk for head trauma.
  • Regularly inspect the area under the headset magnet to monitor for proper adhesion and to check for appropriate magnet strength.
  • Perform daily listening checks of the microphone to ensure clear sound quality.
  • Refrain from tugging at, twisting, or throwing external processor components.
  • Perform daily listening checks (i.e., Ling Six-Sound Test) to see that the child perceives a variety of sounds with the device (e.g., parent/caregiver, speech-language pathologist, teacher, audiologist).

Parents and caregivers are key to the (re)habilitation process after cochlear implantation. They may require guidance on effective communication strategies, expectations for CI reliability (e.g., possibility of reimplantation at a future date), outcome considerations, importance of wear time, and participation restrictions or instructions (e.g., sports, swimming).

It is often difficult to predict how successful a child will be in obtaining age-appropriate communication milestones, and there is significant variability across recipients in rate of progress as well as in ultimate outcomes. Even in instances of successful surgery and properly functioning device(s), limited outcomes may still occur due to other variables. Early implantation is one factor that has been associated with successful outcomes (Sharma & Campbell, 2011). A number of additional variables may affect the user's benefit from the implant and the user's development of listening and spoken language skills (Cosetti & Waltzman, 2012; Geers, Strube, Tobey, Pisoni, & Moog, 2010).

Aural (Re)Habilitation

The process of aural habilitation is designed to help a person with hearing loss attain listening and communication skills that they have yet to acquire (i.e., prelingual). Aural rehabilitation is an interactive and individualized process. The goal is to help a person with hearing loss maintain, reestablish, or improve listening skills and communication function while preventing or minimizing limitations on a person's well-being and communication due to auditory dysfunction (i.e., postlingual). Interpersonal, psychosocial, educational, and vocational functioning may be considered.

After cochlear implantation, the child will receive aural (re)habilitation services to learn how to listen and understand the range of sounds (e.g., environmental sounds, spoken language, music) conveyed via the device. The treatment plan is individualized to each child based on age, developmental norms, hearing history, and specific needs. For example, a focus of treatment for very young children is speech and language development, including vocalizations, speech sounds, articulation/intelligibility, listening, and spoken language. In contrast, the treatment plan for school-age children may address academics and self-confidence, whereas teens and young adults may benefit from goals regarding independence, self-advocacy, and adjustment to higher education.

The communication method(s) used by the family/caregivers will influence the specific goals and activities involved in an individual child's aural (re)habilitation. Successful and continuous family/caregiver involvement is a critical part of the process.

Approaches

There are several communication options for children with CIs:

  • Auditory-verbal (listening and spoken language): The use of listening skills to acquire and use spoken language in instances where listening and spoken communication may be used exclusively.
  • Auditory-oral: The use of listening and spoken communication along with speech reading, repetition, and/or visual cues.
  • Cued speech: The use of a visual communication system using specific hand shapes and placements.
  • Total communication: The use of a combination of communication modalities simultaneously, including spoken language, English-based sign language, writing, gestures, and facial expressions.
  • American Sign Language (ASL): The use of a visually based, manual sign language.

Successful CI users may use any of these approaches. The CI team should repeatedly review the family's/caregivers' long-term goals and vision for the child, noting whether the current communication approach aligns with those goals and that vision.

Communication modes can be implemented alone or in combination with one another (e.g., use of auditory skills and spoken language in combination with manual communication). Selection of communication approach is not a one-time decision but, rather, a dynamic process that allows for changes over time. It is common for families/caregivers to change communication methods or educational placement as the child's skills evolve and as his or her individual needs change.

Components

An aural (re)habilitation plan may include some or all of the following components, which should always reflect the individual needs and developmental level of the child:

  • Auditory Training: Specific listening activities focused on improving speech perception (synthetic, analytic) and functional listening skills.
  • Language Development: Activities focused on receptive and expressive development across communication domains (phonology, morphology, syntax, semantics).
  • Communication Skills Training: Activities for developing social interaction skills, conversational strategies, and repair strategies.
  • Voice Therapy: Activities focused on resonance and speech rhythm.
  • Speech Sound Production Training: Activities focused on articulation and intelligibility.
  • Speech Reading: Activities focused on the use of lip reading, facial expressions, gestures, and other nonverbal means.
  • Music Training: Activities focused on musical experiences that are age appropriate, including concepts such as melody and rhythm.
  • Executive Functioning: Goals typically integrated into other activities that address, for example, strategy use, emotional regulation, working memory, and attention.
  • Counseling and Education for Child and Family/Caregivers: Topics include hearing device care and management, realistic expectations, community resources, listening strategies, impact of environment on listening conditions, self-advocacy skills, and support groups (e.g., local, state, national, manufacturer-specific).

Hearing Assistive Technology

Hearing assistive technology systems (HATS) improve speech understanding in difficult listening situations by increasing the signal-to-noise ratio. HATS may be used in conjunction with a CI. Adverse conditions affecting communication may include distance between the speaker and listener, competing noise, poor room acoustics, and poor room lighting. Several types of HATS may be used with CIs to improve listening experiences and outcomes. Devices may include frequency modulation (FM) or digital modulation (DM) systems, wireless accessories, infrared systems, Bluetooth adaptors, amplified and captioned telephones, audio loops, and amplified and/or visual alarms (baby monitor, clock alarm, doorbell, smoke detector). See ASHA's resource on Hearing Assistive Technology for more information.

International Classification of Functioning, Disability and Health

The World Health Organization (WHO) published the International Classification of Functioning, Disability and Health (ICF) in 2001 as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in patient care management, both in establishing goals and in determining specific outcomes that can be measured through patient report. See the ASHA resource on ICF for more information.

Cultural Considerations

Members of the Deaf community share a common culture. Some of these members also acculturate into the hearing culture. Alignment with one's culture as well as the level of acculturation into other cultures may significantly influence acceptance, compliance, and decision making regarding treatment. See the ASHA Practice Portal page on Cultural Competence for more information.

Service Delivery

In addition to determining the optimal treatment options for each child receiving a CI, the audiologist, speech-language pathologist, and other interdisciplinary team members also consider service delivery variables. Examples of variables that may affect treatment outcomes include format, provider, dosage, timing of implantation, and setting.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.