ERIC EJ623184: The Effectiveness of Cochlear Implants for Children with Prelingual Deafness.

13 Pages·2000·0.11 MB·English

by  ERIC

Journal of Early Intervention
http://jei.sagepub.com
The Effectiveness of Cochlear Implants for Children With Prelingual Deafness
Ann M. McKinley and Steven F. Warren
Journal of Early Intervention 2000; 23; 252
DOI: 10.1177/10538151000230040501
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JournalofEarlyIntervention,2000
Vol.23,No.4,252–263
Copyright2000bytheDivisionofEarlyChildhood,CouncilforExceptionalChildren
The Effectiveness of Cochlear Implants for
Children With Prelingual Deafness
ANN M. McKINLEY
Vanderbilt University
STEVEN F. WARREN
University of Kansas
No longer considered an experimental procedure, cochlear implantation in young children with
profound hearing loss has become almost commonplace. This paper reviews the efficacy of
cochlear implantation in children with prelingual deafness. First, a brief introduction to
cochlear implants is provided. Second, research regarding the effects of cochlear implantation
in children with prelingual deafness on speech perception, speech production, and language
development is reviewed. Finally, implications for early childhood educators are discussed.
The development of cochlear implants is one fessionals view deafness as a condition to be
of the most significant interdisciplinary bio- diagnosed and treated, the Deaf community
medical achievements to date (Clark, Cowen, seesdeafnessasadifference,notadeficit.Ac-
& Dowell, 1997). This therapeutic break- cording to Lane and Bahan (1998), Deafpeo-
through has been the subject of widespread ple have a language and are a cultural minor-
media attention in recent years as its effects ity, and the world of deafness is distinctive,
have been increasingly reported in scientific rewarding, and worth preserving.
journals (e.g., Balkany, 1993; Bonn, 1998; Many deaf advocates consider cochlearim-
Osberger, Maso, & Sam, 1993). As technolo- plants as genocidal to the Deaf culture (Lane
&Bahan,1998).Theyarguethatimplantation
gy continues to improve,publicawarenessin-
ofchildrenconflictswiththerightoftheDeaf
creases, and the age of implantation lowers,
cultural minority to exist and flourish. Al-
young children with cochlearimplantsarebe-
though these issues have been raised, this pa-
coming common in various types of early
per is written simply to evaluate the perfor-
childhood educational settings.
manceofchildrenwhohavereceivedcochlear
This paper reviews the empirical evidence
implants.WedonotwishtodiscredittheDeaf
of the efficacy of cochlear implantation in
community or the potential value of manual
children with prelingual deafness. We ac-
communication. Instead, we recognize that
knowledgethatitisalmostimpossibletowrite
there are parents of deaf children who desire
a paper on this topic without addressing the
that their child learn verbal communication.
controversy surrounding the use of cochlear
With this in mind, wehaveprovidedacritical
implants for children. Cochlear implant pro-
review of the research literature, examining
fessionals have met tremendous opposition the effectiveness of cochlear implants on the
from the Deaf community. Members of the development of verbal communication skills
Deafcommunitydifferentiatetheterm‘‘deaf’’ in children with prelingual deafness. In addi-
that is used to describe a pathology, from the tion, we addressed issues that early childhood
term ‘‘Deaf,’’ which denotes a culture and a educators, who come in contact with children
sense of pride. Whereas many medical pro- with cochlear implants, might face.
252 JEI, 2000, 23:4
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Figure 1.
Internal and external components as worn by the cochlear implant recipient.
A Primer on Cochlear Implants ternal components consist of a microphone, a
A cochlear implant is an electronic device speech processor, and a transmitter, which
providing auditory information to individuals sends the signal to the internal components
who have severe to profound sensorineural (see Figure 2). Cochlear implant surgery is
hearing loss in both ears and receive limited usually a 2- to 3-hour procedure, performed
or no benefit from conventional hearing aids. by an otolaryngologist (ear, nose, and throat
Typically, these individuals have pure-tone surgeon). The child typically spends 1 night
thresholdsof100dBHLorgreater.Theorigin inthehospitalfollowingcochlearimplantsur-
of profound deafness is usually damaged or gery. Approximately 4 weeks following sur-
diminished hair cells in the inner ear (Hen- gery, the child returns to the implant center
derson, Salvi, Boettcher, & Clock, 1994). Be- for the initial stimulation of the device. This
cause of the amount of hair cell damage, initial ‘‘tune-up’’ session usually takes 2 to 3
merelyamplifyingsounddoesnotenablepeo- days depending on the child’s age and level
ple with profound deafness to process sound. ofcooperation.Anaudiologiststimulateseach
Unlike conventional hearing aids, which de- oftheimplantedelectrodesanddeterminesthe
liver amplified sound to the ear, a cochlear child’s threshold and comfort levels. Once
implantbypassesdamagedhaircellsandstim- threshold levels and comfort levels have been
ulates the auditory nerve directly withelectri- obtained for each of the electrodes, a map of
cal current.Cochlearimplantshavebeenused these levels is created and programmed onto
in research trials with adult patients since the thechild’sspeechprocessor.Initially,thechild
mid-1970s but did not receive Food andDrug will have to make frequent visits to the audi-
Administration (FDA) approval for clinical ologist to fine-tune the map. After that, ad-
use in children until 1989. Currently,children justments to the child’s map will be made pe-
overtheageof18monthswhohaveprofound riodically as perceptual performance changes.
bilateral sensorineural hearing loss and dem- Several modifications have been made to
onstrate limited benefit from conventional the cochlear implant device components and
hearing aids might be considered candidates speechprocessingstrategiesasthetechnology
for cochlear implants. More than 20,000 peo- hasevolved.Currently,threecochlearimplant
ple around the world, half of them children, devices have been cleared by the FDA for
have received cochlear implants since the clinical use. The Cochlear Corporation re-
clinical introduction of the device (Bonn, ceived FDA approval for clinical use of the
1998). Nucleus 22 cochlear implant in children in
A cochlear implant is comprisedofinternal 1989. This device was subsequently replaced
and external components (see Figure 1). The by the Nucleus 24 cochlear implant in 1998.
internal components consist of electrodes, In 1997, the Advanced Bionics Corporation
whicharesurgicallyplacedinthecochlea(in- receivedFDAapprovalfortheuseoftheClar-
ner ear), and a receiver or stimulator, which ion cochlear implant in children. A fourth de-
lies beneath the skin behind the ear. The ex- vice, the COMBI 40(cid:1), manufactured by the
McKinley & Warren 253
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Figure 2.
Illustration of the external device of a cochlear implant.
Med.El.Cooperation,iscurrentlyundergoing onset of deafness, age of implantation,speech
clinical trials. The most significant advance- processor type, number of implanted elec-
ment in cochlear implant technologyhasbeen trodes, duration of deafness, communication
in speech processing. Whereas the cochlear mode,anddurationofimplantuse(Miyamoto
implant devices of the early 1990s encoded et al., 1994). In addition, it is possible that
only specific features of speech, the current implant success is affected by the physiolog-
devices encode the entire speech signal. ical functioning of the surviving neurons in
In addition to device alterations, therehave the auditory nerve, the position of the elec-
been changes in the demographic character- trodes in relation to excitable tissue, neural
istics of children undergoing cochlearimplant supply to the cochlea, the central processing
surgery. Specifically, children are receiving abilities,andthechild’scognitiveandlinguis-
implants at a younger age because research tic abilities. Furthermore, the quality of audi-
hascontinuedtosuggestsuperiorperformance tory training, parental motivation,and teacher
associated with early implantation(Miyamoto expectations might also influence the amount
et al., 1994). In 1998, the FDA lowered the of success a child achieves with a cochlear
minimal age of pediatric implantation from implant. Finally, the child’s success is depen-
two years to 18 months of age. dent on the parents’ insistence and the child’s
complianceinwearingtheexternaldevicefull
Performance of Children With Cochlear time.
Implants When investigating the performance of
Because children with profound sensorineural children with cochlear implants, it is impor-
hearing loss constitute a very heterogeneous tant to differentiate between children who be-
population, performance of children with co- camedeafprelinguallyandthosewhobecame
chlear implants varies greatly. Factors asso- deaf postlingually. Children with prelingual
ciated with the amount of benefitthe childre- deafnessmightnotdemonstratetheimmediate
ceives from a cochlear implant include age of successseeninchildrenwithpostlingualdeaf-
254 JEI, 2000, 23:4
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© 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution.
ness. Children with postlingual deafness have thespeechperceptionperformanceofchildren
had some language and auditory experiences with cochlear implants.
prior to the onset of deafness and, therefore,
might be expected to benefit from a cochlear Speech Perception
implant at a faster rate than those with prelin- Speech perception skills progress develop-
gual deafness do. The aim of this paper is to mentally, beginning with speech detection,
examine the effectiveness ofcochlearimplan- then discrimination, recognition, and finally
tation in children with prelingual deafness. comprehension. Speech perception abilities
Whereas a number of studies have included are typically evaluated using closed-set tests,
children who became deaf after the age of 3 which measure speech discrimination, or
years,weonlydescribestudiesthatexclusive- open-set tests, which measure speech recog-
ly evaluated implant performance of children nition. In closed-set tests, a small set of an-
who became deaf prior to the age of 3 years. swers is provided from which the child must
Several studies are not included in this re- choose the correct response. In open-set tests,
viewbecausethey did not meetourcriteriaof the examiner presents a word or phrase and
thechildmustrespondbyrepeatingorsigning
internalvalidity.Todeterminethebenefitchil-
the word. Open-set measures of speech per-
drenreceivefromacochlearimplant,itisnec-
ception are considered more difficult than
essary to minimize extraneous variables, par-
closed-settestsbecausethepossibleresponses
ticularly maturation and education.Therefore,
are not provided to the child.
this paper only reviews longitudinal studies
Speech perceptionperformanceofcochlear
including a control group consisting of chil-
implant versus hearing aid users. When co-
dren without cochlear implants.
chlear implantation was first recognized as a
Werecognizethatsomeresearchinthearea
possible habilitative component for deaf chil-
of cochlear implants is criticized for having
dren,theevaluationofspeechperceptionabil-
selection bias. Because it is up to parents to
ities of children who receive cochlear im-
decide whether or not their child undergoes
plants versus those who used conventional
cochlear implantation, random assignment to
hearing aids or tactile aids became the focus
treatment groups is impossible. It is conceiv-
of several researchers.
able that there are characteristics inherent in
Afewstudiescomparedtheperformanceof
children who receive cochlear implants that
children who received cochlear implants to
differ from those in children who do not re-
the performance of children who used multi-
ceive cochlear implants. Particularly, it might
channel tactile aids. Miyamoto, Robbins, Os-
bearguedthatchildrenwithcochlearimplants
berger, Riley, and Kirk (1995) compared the
come from families who have a stronger de-
speech perception performance of children in
sire for their child to develop verballanguage
the predevice condition and at a post-device
skills, than the families of children without
intervalafteranaverageof1.5yearsofdevice
cochlear implants. Although this potential
use. The results demonstratedstatisticallysig-
source of bias might have a slight influence
nificant improvement in closed-set and open-
on these studies, it is unlikely that it accounts set word recognition between the predevice
for the notable effect. and postdevice condition for thechildrenwho
The majority of research on the perfor- received cochlear implants, but not for the
mance of children with cochlear implants has children who used the tactile devices. In ad-
been in the area of speech perception. The dition, the scores of the cochlear implant
number of studies examining speech produc- group were statistically significantly higher
tion and language skills has been more limit- thanthescoresofthetactilegrouponallmea-
ed. Becausetheperceptionofspeechisanec- sures after 18 months of device use.
essary requisite to speech production and the Geers and Tobey (1995) assessed the
acquisition of an oral language, we will first speech perception abilities of children with
describe current research findings regarding cochlear implants and children who wore tac-
McKinley & Warren 255
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tile devices. After 12 months of device use, implantation allows deaf children access to
the auditory speech perception scores of chil- auditory information during the preschool
drenwithcochlearimplantsexceededthoseof years, which might positively impact the de-
children with a similar hearing loss whowore velopment of speech and language. Miyamo-
tactile devices.Inaddition,statisticallysignif- to, Kirk, Svirsky, and Sehgal (1999) selected
icant improvements in lip-reading abilities children with prelingual deafness, who re-
were documented in the cochlear implant ceived a cochlear implant prior to 5 years of
group but not in the tactile aid group. Similar ageandexaminedtheirspeechperceptionper-
findingswerereportedbyCarneyetal.(1993) formance asafunctionofageatimplantation.
who found that children with multi-channel These children were administered speech per-
cochlear implants statistically significantly ception tests prior to receiving their implant,
outperformed children using tactile aids on a and then at 6-month intervals following im-
change/no change speech discrimination pro- plantation. For each subject, data were ana-
cedure. lyzed until the child’s chronological age was
Vermeulen, Beijk, Brokx, van den Borne, closest to 4 years and 6 months.Resultsdem-
and van den Broek (1995) compared the onstrated that, on average, the children who
speech perception of children with cochlear received their cochlear implant prior to 3
implants to the speech perception of children years of age achieved higher speech percep-
withanequivalenthearinglosswhousedcon- tion scores than children who received their
ventionalhearingaids.After12monthsofde- cochlear implants after that time did. As ac-
vice use, the children with cochlear implants knowledged by the authors, however, this
performed statistically significantly better on study was confounded by the fact that the
every measure than the children who wore children who received their implants at youn-
hearing aids did. Whereas the cochlear im- ger ages also had more years of experience
plantgroupachieved61%onadiscrimination with their device than the children who re-
task of segmental aspects of speech, the hear- ceived cochlear implants after the age of 3
ing aid group scored 23%. years. It is not clear if the speech perception
Five studies have comparedthespeechper- abilities of children who received their co-
ceptionperformanceofchildrenwithcochlear chlear implants at older ages will ultimately
implants to the performance of children with plateau at the same level.
varying amounts of residual hearing who Todate,nostudieshavebeenpublishedthat
wore conventional hearing aids (Geers, 1997; exclusively compared the speech perception
Geers & Moog, 1994; Miyamoto, Kirk, Todd, abilitiesofchildrenwhoreceivedcochlearim-
Robbins, & Osberger, 1995; Myer, Svirsky, plants beyond the age of 5 years, to age-
Kirk, & Miyamoto, 1998; Svirsky & Myer, matched children who continued to use con-
1999). Collectively, these studies assessed ventional amplification. However, using a re-
open-set and closed-set speech phoneme, peatedmeasuredesign,Osberger,Fisher,Zim-
word, and sentence perception abilities. Re- merman-Phillips, Geier, and Barker (1998)
sultsofallfivestudiesdemonstratedthatafter compared preoperative performance with
an average of 2 to 3 years of device use,chil- hearing aids to postoperative performance
dren with cochlear implants outperformed with cochlear implants after 3 and 6 months
children with hearing aids who had pure tone of device use in children who received their
hearing thresholds greater than 100 dB HL, cochlear implants after the age of 5 years.
and performed comparably to children with Their findings demonstrated statistically sig-
hearing aids whose hearing thresholds were nificant improvement in both closed-set and
between 90 and 100 dB HL. open-set speech perception abilities over time
Speechperceptionandearlyversuslateco- following cochlear implantation, particularly
chlear implantation. There is a world-wide inchildrenwhowereeducatedthroughanoral
trendtowardsgivingcochlearimplantstodeaf modality. Although unlikely, it cannot be
children at increasingly younger ages. Early ruled out that the children in this study might
256 JEI, 2000, 23:4
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© 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution.
have achieved similar gains in speech percep- nificant improvement only in the production
tion had they continued to use their conven- of diphthongs.
tional hearing aids. Nevertheless, the child’s Spencer, Tye-Murray, and Tomblin (1998)
age is an important consideration forcochlear reported that children with cochlear implants
implant candidacy if the child has prelingual comprehend more and use more bound mor-
deafness.Theexpectationsofparentsandpro- phemes in theirspontaneous speechthanchil-
fessionalsmightneedtobereadjustedforold- dren who use conventional hearing aids do.
er children undergoing cochlear implantation. Finally, findings from Tye-Murray, Spencer,
andWoodworth(1995)indicatedthatchildren
withprelingualdeafnesswhoreceivecochlear
Speech Production
implants prior to the age of 5 receive greater
The acquisition of intelligible speech is often
benefitfromtheircochlearimplantintermsof
the goal of parents and teachers of children
speech production than children who receive
with cochlear implants. The acoustic benefits
a cochlearimplant afterthe ageof5yearsdo.
providedbyacochlearimplantmightcontrib-
ute to articulation of precise speech. Speech
Language Development
production, however, typically does not
Although improved speech intelligibility is
change as quickly as speech perception. Al-
typically the focus of parents and teachers of
though there might be slow progress during
deaf children, speech skills do not directlyre-
the first 2 years following implantation, it has
flect language competence. Speech refers to
been suggested that speech production will
oral production, whereas language refers to
improve as long as the child is trained and
the abstract knowledge basis of symbolic
challenged in an oral modality (Nevins &
communication. The ultimate goal for chil-
Chute, 1996).
dren with prelingual deafness who have co-
Research has demonstrated that speech in-
chlear implants is to integrate auditory infor-
telligibility of children with cochlearimplants
mationprovidedbytheirdevicesintotheirde-
increases graduallyovertime.AstudybyMi-
veloping language system (Hasenstab & To-
yamotoetal.(1997)demonstratedthatspeech
bey, 1991).
intelligibilityofprelinguallydeafchildrenim-
The Sensory Aid Study conducted at the
provedfrom0%priortoimplantation,to40%
Central Institute for the Deaf (Geers, 1997;
after 4.5 to 7.5 years of device use. In addi-
Geers & Moog, 1994), longitudinally com-
tion, after 2 years of device use, the speech
pared language acquisition of children with
intelligibility of children with cochlear im-
cochlearimplantsandchildrenwithothersen-
plants surpassed the speech intelligibility of
sory aids (i.e., conventional hearing aids and
hearing aid users whose pure-tone auditory tactileaids).Thechildrenrangedfrom2to12
thresholds averaged 100–110 dB HL. Rob- years of age at the beginning of the study.
bins, Kirk, Osberger, and Ertmer (1995) re- Participants’ language performance was eval-
ported similar findings. uated based on spontaneous language sam-
Ertmer, Kirk, Sehgal, Riley, and Osberger ples, receptive and expressive vocabulary
(1997) compared vowel production by chil- tests, and a battery of language tests normed
drenwithcochlearimplantstothatofchildren on children with a hearing impairment. Re-
with multi-channel tactile aids, and demon- sults demonstrated statistically significant im-
stratedbetterperformanceofchildrenwithco- provement in all sensory aid groups on all
chlearimplantsthanchildrenwithtactileaids. measures. After 3 years, the performance of
Specifically, they found that after an average children with cochlear implants was superior
of 20 months of device use, children with co- to all other groups of children who had pure-
chlear implants showed a statistically signifi- tone thresholds of 100(cid:1) dB HL (essentially
cant improved production of diphthongs and noresidualhearing)andsimilartothehearing
most vowel categories, whereas the children aiduserswhohadpure-tonethresholdsof90–
withtactileaidsdemonstratedstatisticallysig- 100dBHL(alimitedamountofresidualhear-
McKinley & Warren 257
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ing).Inaddition,resultsindicatedthatthedeaf velopment of 29 children with prelingual
childrenusinghearingaidsprogressedintheir deafness who wore conventionalhearingaids.
vocabulary development at a slower rate than Children received cochlear implants between
normally hearing children did, whereas the the ages of 2 and 13 years. Samples of ex-
vocabulary development of children with co- pressivelanguagewereobtainedfromallchil-
chlear implants progressed at the same rateas dren using story recall. These samples were
that of normally hearing children. analyzedusingtheIndexofProductiveSyntax
Miyamoto, Svirsky, and Robbins (1997) scoring system (Scarborough, 1990). In addi-
also examined the efficacy of cochlear im- tion, the children with cochlear implantswere
plants in children with prelingual deafness on administered the Rhode Island Test of Lan-
language acquisition. In this study, cross-sec- guageStructure(Engen&Engen,1983)toas-
tional data from 89 children with prelingual sess sentence comprehension. The normspro-
deafness who had not received cochlear im- vided by the test were used to represent per-
plants were used to obtain a regression slope, formance by deaf children without cochlear
which the authors referred to as the ‘‘deaf implants. Results indicated superior language
slope.’’ The deaf slope was then used to ob- achievement by children with cochlear im-
tain a predicted score for the children with plants compared to their peers without im-
cochlear implants. Longitudinal data were plants. Performance on the Index of Produc-
then collected on 23 children with cochlear tive Syntax indicated that children with co-
implants and compared to the predicted deaf chlearimplantsscoredhigheronallsubscales,
slope. Children were tested between 0 and 3 than did the control group ofchildrenwithout
months before implantation and at 6 and 12 implants. In addition, scores on the Rhode Is-
months postimplantation. Results indicated land Test of LanguageStructuredemonstrated
that profoundly deaf children without im- a mean percentile rank of 95% for children
plants,onaverage,couldbeexpectedtomake with cochlear implants, based on norms from
only 5 months of language growth in 1 year. chronologically age-matched deaf peers. This
The language growth of children with cochle- study supports the growing body of evidence
ar implants exceeded the predicted growth by of the benefits of cochlear implants on lan-
7.1 and 6.9 months for expressive and recep- guage comprehension and production.
tive language, respectively. In addition, the
authors reported that during the 1st year fol- Summary
lowing implantation, the rate of language de- Research has demonstrated the positive ben-
velopment was the same for deaf children efits of cochlear implants on the speech per-
with cochlear implants as for normally hear- ception, speech production, and language de-
ing children. Consequently, the gap in lan- velopment of young children with prelingual
guage scores between children with implants deafness. Anecdotal reports, not described
and children with normal hearing did not in- here,havealsoindicatedpositiveoutcomesof
crease, but remained constant during the 1st cochlear implants on reading skills, academic
year.Theauthorssuggestedthatthesefindings achievement, and social acceptance (Bonn,
support early implantation because there is a 1998; Nevins & Chute, 1995; Radcliffe,
smallerlanguagegapbetweenadeafchildand 1999), but empirical research in these areasis
his or her hearing peers at a younger versus needed. Additional research examining the
an older age. performance of children with cochlear im-
Tomblin, Spencer, Flock, Tyler, and Gantz plants continues. Future research seemslikely
(1999) also conducted a study comparing the to document even more impressive levels of
language achievement of children with and performance, as studies begin to reflect the
without cochlear implants. These researchers improvedspeechprocessingofthecurrentde-
compared the English language development vices and the trend toward children receiving
of 29 children with prelingual deafness and implants at a younger age. A clearer under-
whohadcochlearimplantstothelanguagede- standing of the vital role of effective habili-
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© 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution.
tative and educational techniques might also technical aspects of the implant and can re-
positively influence the level of child perfor- solve problems with the device.
mance reported in future investigations. Although audiologists, otolaryngologists,
and speech-language pathologists at the im-
Implications for Early Childhood plant center might make up the core of the
Educators implant team, it is essential toincludeadjunct
Universal newborn hearing screenings, early members relevant to the life of the candidate,
identification, advanced technology, height- such as the child’s teacher or caregiver. Their
ened public awareness, and positiveempirical input is instrumental for decisions regarding
findings are all likely to increase the frequen- cochlear implant candidacy and auditory as
cy in which early childhood educators come well as linguistic goals. For example, they
in contact with young children with cochlear might provide information not readily avail-
implants. Unlike their deaf peers, who have able to the rest of the implant team, such as
onlyminimalaccesstoauditorycues,children the child’s academic progress, motivation to
with cochlear implants have the capacity to communicateverbally,andsocialskills.Inad-
use the auditory code as the primary source dition, because they observe the child daily,
of language development and learning. Early they might be the first to recognize perfor-
childhood educators are likely to encounter mance changes indicating the need for an ad-
these children in a variety of educationalcon- justment of the child’s speech processor map.
texts, including inclusive settings. Conse- Eachprofessionalcontributesarequisitecom-
quently,itisimportantthatearlyintervention- ponent to the child’s success. Parents and
istsandearlychildhoodeducatorsarefamiliar teachers become more integral members of
with cochlear implants, the auditory benefit the implant team when a communicative link
provided by implants, and the components of is established between the implant center and
a successful habilitative or educational pro- thechild’sschool.Ideally,thiscommunicative
gram.Thefollowingdiscussionfocusesonthe link is initiated when the child is assessed as
fundamentals of an optimal educational envi- a potential candidate for a cochlear implant
ronment for young children with cochlearim- and then continues indefinitely.
plants.
Analytical Therapy Versus Naturalistic
A Communicative Link Habilitation
Children with cochlear implantsmightbenefit As Robbins (1998a) explained, the enhanced
considerably from the existence of an estab- auditory capacity afforded by a cochlear im-
lished communicative link between the im- plant and the younger age of implantationhas
plantcenterandtheirschoolorchild-carecen- altered the focus of habilitativetechniquesfor
ter (Stojny, Harrison, & Zimmerman-Phillips, deaf children with cochlear implants. Tradi-
1998). At the implant center, the child is typ- tionally, auditory and linguistic training for
ically seen by a team ofprofessionals,includ- children with profoundsensorineuraldeafness
ing an audiologist, an otolaryngologist, a hasbeencenteredonverynarrow,didacticex-
speech-language pathologist, and often a psy- ercises designed to facilitate sound detection,
chologist.Elsewhere,achildmightbeinclose discrimination, identification,andcomprehen-
contact with a classroom teacher, school sion. Auditory Verbal Therapy is an example
speech-language pathologist, itinerantteacher, of a habilitative program using this type of
or child care provider. Professionals obtain analytical auditory training exercises to facil-
important information about the child, and itate verbal communication in children with
their areas of expertise are essential to maxi- severe to profound hearing loss. These types
mize the child’s education and development. of structured exercises are advocated particu-
Members of the cochlear implant team have larly for older children who have had limited
expertise to assess the child’s potential with a listening experiences.
cochlear implant. They also specialize in the Cochlear implants provide deaf children
McKinley & Warren 259
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with auditory information not previously ac- at the time of implantation dictates whether
cessible through their hearing aids, particular- the intervention program should emphasize
ly at the high frequencies. Therefore, the ac- direct or indirect instruction. Whereas older
quisition of spoken English as a primary lan- childrenandadultsmightbenefitsubstantially
guage is often a goal for deaf children with from direct instruction and rote exercises to
cochlear implants. Because of their enhanced facilitate the development of auditory skills,
auditory capabilities and focus on spoken En- younger children are likely to derive greater
glish,ithasbeensuggestedthatthesechildren listening and language benefits from contex-
reap greater benefits from a more naturalistic tualized and incidental experiences.
rather than a direct approach to language and Although it has not been empirically dem-
auditory learning (e.g., Robbins, 1998a; Nev- onstrated, clinical observation attests that, in
ins & Chute, 1996). addition to their naturalistic learning experi-
These clinical observations mirror empiri- ences, most children with cochlear implants
cal data about children with normal hearing will require structured auditory exercises to
that indicate that young children generally advance their listening skills. Estabrooks
learn more efficiently from naturalistic or in- (1998) suggested that these structured activi-
cidentalexperiencesthanfromdirectteaching ties are most effective when they incorporate
experiences, until the mean length of utter- meaningful communication skills appropriate
ances is atleastthreemorphemeslong(Yoder for the child’s linguistic and cognitive levels,
& Warren, 1998). Children with cochlear im- and occur as a natural consequence of an ac-
plants have the potential to enhance their lis- tivity. Ideally, the clinician or educator con-
tening and learning skills throughreal-lifeex- ducting the therapy session will integrate lan-
periences. Cochlear implants provide the ca- guagegoalsintothelisteningtasks.Tradition-
pability for deaf children to generalize and alauditorytrainingwhichisslightlymodified,
learnfromnaturalisticandincidentaleventsat mightgreatlyenrichthemeaningfulnessofthe
a level not previously possible with conven- task for the child. For further suggestions for
tionalhearingaids.Habilitationforthesechil- designing meaningful listening activities, the
dren, therefore, should more closely mirror reader is referred to Estabrooks (1998), Nev-
theeducationofchildrenwithnormalhearing. ins and Chute (1996), and Robbins (1998b).
That is, intervention should focus on teaching
a broad array of developmentally appropriate Supporting Parental Efforts
targets in a naturalistic environment with the Parentsandthehomeenvironmentmighthave
idea that the child will generalize what he or the greatest impact on the auditory develop-
she learns to other contexts and other targets mentof thechildintheearlyyearsofimplant
(Robbins, 1998a).For example,parentsmight use. Young children often interact with their
focus on getting their 18-month-old child to parents off and on many hours a day, 7 days
identify and produce his or her name in the a week, year in and year out. The cumulative
context of daily routines. At preschool, the effect of this environment, either positive or
child might learn auditory or listening skills negative, has shown to be quite substantial
best in the context of the existing curriculum. (e.g., Hart & Risley, 1995). For that reason,
TheinterestedreaderisreferredtoEstabrooks the role of early childhood professionals
(1998)andRobbins(1998a)forcreativeclass- should be to equip parents to provide an en-
room activities enhancing incidental and gen- riched language environment for their child.
eralized learning in young children with co- Likewise, one can presume that the effects
chlear implants. of a cochlear implant on a child’s language
Theageofimplantationmightinfluencethe development will depend, to some extent, on
typeoflearningenvironmentmostoptimalfor the level of use of the device. Compliance
children with cochlear implants. Based on with wearing the devices is one of the more
their clinical experience, Nevins and Chute frequent issues facing parents of young im-
(1996)havesuggestedthattheageofthechild plant recipients. A strong-willed child might
260 JEI, 2000, 23:4
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© 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution.