Journal of Early Intervention

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

The online version of this article can be found at: http://jei.sagepub.com/cgi/content/abstract/23/4/252

Published by:

http://www.sagepublications.com

On behalf of:

Division for Early Childhood of the Council for Exceptional Children

Additional services and information for Journal of Early Intervention can be found at:

Email Alerts: http://jei.sagepub.com/cgi/alerts

Subscriptions: http://jei.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Citations (this article cites 31 articles hosted on the SAGE Journals Online and HighWire Press platforms): http://jei.sagepub.com/cgi/content/refs/23/4/252

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. Journal of Early Intervention, 2000 Vol. 23, No. 4, 252–263 Copyright 2000 by the Division of Early Childhood, Council for Exceptional Children 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, sees deafness as a difference, not a deficit. Ac- & Dowell, 1997). This therapeutic break- cording to Lane and Bahan (1998), Deaf peo- 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 cochlear im- Osberger, Maso, & Sam, 1993). As technolo- plants as genocidal to the Deaf culture (Lane gy continues to improve, public awareness in- & Bahan, 1998). They argue that implantation creases, and the age of implantation lowers, of children conflicts with the right of the Deaf young children with cochlear implants are be- cultural minority to exist and flourish. Al- coming common in various types of early though these issues have been raised, this paper is written simply to evaluate the perfor- childhood educational settings. mance of children who have received cochlear This paper reviews the empirical evidence implants. We do not wish to discredit the Deaf 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 knowledge that it is almost impossible to write 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, we have provided a critical 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 Deaf community differentiate the term ‘‘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

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 thresholds of 100 dB HL or greater. The origin in the hospital following cochlear implant sur- 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 merely amplifying sound does not enable peo- days depending on the child’s age and level ple with profound deafness to process sound. of cooperation. An audiologist stimulates each Unlike conventional hearing aids, which de- of the implanted electrodes and determines the liver amplified sound to the ear, a cochlear child’s threshold and comfort levels. Once implant bypasses damaged hair cells and stim- threshold levels and comfort levels have been ulates the auditory nerve directly with electri- obtained for each of the electrodes, a map of cal current. Cochlear implants have been used these levels is created and programmed onto in research trials with adult patients since the the child’s speech processor. Initially, the child mid-1970s but did not receive Food and Drug 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- over the age of 18 months who have profound 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 speech processing strategies as the technology for cochlear implants. More than 20,000 peo- has evolved. Currently, three cochlear implant 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 comprised of internal 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 which are surgically placed in the cochlea (in- received FDA approval for the use of the Clar- 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 40ϩ, manufactured by the

McKinley & Warren 253

Med. El. Cooperation, is currently undergoing onset of deafness, age of implantation, speech clinical trials. The most significant advance- processor type, number of implanted elec- ment in cochlear implant technology has been trodes, duration of deafness, communication in speech processing. Whereas the cochlear mode, and duration of implant use (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, there have 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 cochlear implant supply to the cochlea, the central processing surgery. Specifically, children are receiving abilities, and the child’s cognitive and linguis- implants at a younger age because research tic abilities. Furthermore, the quality of audi- has continued to suggest superior performance 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 compliance in wearing the external device full 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- came deaf prelingually and those who became chlear implants varies greatly. Factors asso- deaf postlingually. Children with prelingual ciated with the amount of benefit the child re- deafness might not demonstrate the immediate ceives from a cochlear implant include age of success seen in children with postlingual deaf-

254 JEI, 2000, 23:4

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 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 the speech perception performance of children 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 of cochlear implan- 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, we only describe studies that exclusive- 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, view because they did not meet our criteria of the examiner presents a word or phrase and internal validity. To determine the benefit chil- the child must respond by repeating or signing dren receive from a cochlear implant, it is nec- the word. Open-set measures of speech per- essary to minimize extraneous variables, par- ception are considered more difficult than ticularly maturation and education. Therefore, closed-set tests because the possible responses this paper only reviews longitudinal studies are not provided to the child. including a control group consisting of chil- Speech perception performance of cochlear dren without cochlear implants. implant versus hearing aid users. When co- We recognize that some research in the area chlear implantation was first recognized as a of cochlear implants is criticized for having possible habilitative component for deaf chil- selection bias. Because it is up to parents to dren, the evaluation of speech perception abilities 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 A few studies compared the performance of 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- be argued that children with cochlear implants 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 verbal language the predevice condition and at a post-device skills, than the families of children without interval after an average of 1.5 years of device cochlear implants. Although this potential use. The results demonstrated statistically sig- 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 the children who 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- than the scores of the tactile group on all mea- ed. Because the perception of speech is a nec- 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

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. 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 dren with cochlear implants exceeded those of years, which might positively impact the de- children with a similar hearing loss who wore velopment of speech and language. Miyamo- tactile devices. In addition, statistically signif- 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 age and examined their speech perception per- findings were reported by Carney et al. (1993) formance as a function of age at implantation. 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. Results dem- 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- with an equivalent hearing loss who used con- tion scores than children who received their ventional hearing aids. After 12 months of de- 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 plant group achieved 61% on a discrimination 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 compared the speech per- abilities of children who received their co- ception performance of children with cochlear 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 To date, no studies have been published that wore conventional hearing aids (Geers, 1997; exclusively compared the speech perception Geers & Moog, 1994; Miyamoto, Kirk, Todd, abilities of children who received cochlear im- 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, peated measure design, Osberger, Fisher, Zim- word, and sentence perception abilities. Re- merman-Phillips, Geier, and Barker (1998) sults of all five studies demonstrated that after 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 Speech perception and early versus late co- following cochlear implantation, particularly chlear implantation. There is a world-wide in children who were educated through an oral trend towards giving cochlear implants to deaf 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

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 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 for cochlear reported that children with cochlear implants implant candidacy if the child has prelingual comprehend more and use more bound mor- deafness. The expectations of parents and pro- phemes in their spontaneous speech than chil- fessionals might need to be readjusted for old- dren who use conventional hearing aids do. er children undergoing cochlear implantation. Finally, findings from Tye-Murray, Spencer, and Woodworth (1995) indicated that children Speech Production with prelingual deafness who receive cochlear The acquisition of intelligible speech is often implants prior to the age of 5 receive greater the goal of parents and teachers of children benefit from their cochlear implant in terms of with cochlear implants. The acoustic benefits speech production than children who receive provided by a cochlear implant might contrib- a cochlear implant after the age of 5 years do. 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 directly re- 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 cochlear implants mation provided by their devices into their de- increases gradually over time. A study by Mi- veloping language system (Hasenstab & To- yamoto et al. (1997) demonstrated that speech bey, 1991). intelligibility of prelingually deaf children im- The Sensory Aid Study conducted at the proved from 0% prior to implantation, to 40% 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- cochlear implants and children with other sen- plants surpassed the speech intelligibility of sory aids (i.e., conventional hearing aids and hearing aid users whose pure-tone auditory tactile aids). The children ranged from 2 to 12 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 dren with cochlear implants to that of children on children with a hearing impairment. Re- with multi-channel tactile aids, and demon- sults demonstrated statistically significant im- strated better performance of children with co- provement in all sensory aid groups on all chlear implants than children with tactile aids. 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 100ϩ dB HL (essentially cant improved production of diphthongs and no residual hearing) and similar to the hearing most vowel categories, whereas the children aid users who had pure-tone thresholds of 90– with tactile aids demonstrated statistically sig- 100 dB HL (a limited amount of residual hear-

McKinley & Warren 257

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. ing). In addition, results indicated that the deaf velopment of 29 children with prelingual children using hearing aids progressed in their deafness who wore conventional hearing aids. 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- pressive language were obtained from all chil- chlear implants progressed at the same rate as dren using story recall. These samples were that of normally hearing children. analyzed using the Index of Productive Syntax Miyamoto, Svirsky, and Robbins (1997) scoring system (Scarborough, 1990). In addi- also examined the efficacy of cochlear im- tion, the children with cochlear implants were plants in children with prelingual deafness on administered the Rhode Island Test of Lan- language acquisition. In this study, cross-sec- guage Structure (Engen & Engen, 1983) to as- tional data from 89 children with prelingual sess sentence comprehension. The norms pro- 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 chlear implants scored higher on all subscales, slope. Children were tested between 0 and 3 than did the control group of children without months before implantation and at 6 and 12 implants. In addition, scores on the Rhode Is- months postimplantation. Results indicated land Test of Language Structure demonstrated that profoundly deaf children without im- a mean percentile rank of 95% for children plants, on average, could be expected to make 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, have also indicated positive outcomes of crease, but remained constant during the 1st cochlear implants on reading skills, academic year. The authors suggested that these findings achievement, and social acceptance (Bonn, support early implantation because there is a 1998; Nevins & Chute, 1995; Radcliffe, smaller language gap between a deaf child and 1999), but empirical research in these areas is 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 seems likely (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 improved speech processing of the current de- 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- who had cochlear implants to the language de- standing of the vital role of effective habili-

258 JEI, 2000, 23:4

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 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 to include adjunct 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 positive empirical 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 only minimal access to auditory cues, children the child’s academic progress, motivation to with cochlear implants have the capacity to communicate verbally, and social skills. In ad- 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 educational con- justment of the child’s speech processor map. texts, including inclusive settings. Conse- Each professional contributes a requisite com- quently, it is important that early intervention- ponent to the child’s success. Parents and ists and early childhood educators are familiar 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- the child’s school. Ideally, this communicative gram. The following discussion focuses on the 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 cochlear im- and then continues indefinitely. plants. Analytical Therapy Versus Naturalistic A Communicative Link Habilitation Children with cochlear implants might benefit 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 implant and the younger age of implantation has plant center and their school or child-care cen- altered the focus of habilitative techniques for 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 of professionals, includ- children with profound sensorineural deafness ing an audiologist, an otolaryngologist, a has been centered on very narrow, didactic ex- speech-language pathologist, and often a psy- ercises designed to facilitate sound detection, chologist. Elsewhere, a child might be in close discrimination, identification, and comprehen- contact with a classroom teacher, school sion. Auditory Verbal Therapy is an example speech-language pathologist, itinerant teacher, 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

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. 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- children and adults might benefit substantially 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, it has been suggested that these children 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- cidental experiences than from direct teaching ties are most effective when they incorporate experiences, until the mean length of utter- meaningful communication skills appropriate ances is at least three morphemes long (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 through real-life ex- ducting the therapy session will integrate lan- periences. Cochlear implants provide the ca- guage goals into the listening tasks. Tradition- pability for deaf children to generalize and al auditory training which is slightly modified, learn from naturalistic and incidental events at might greatly enrich the meaningfulness of the a level not previously possible with conven- task for the child. For further suggestions for tional hearing aids. Habilitation for these chil- designing meaningful listening activities, the dren, therefore, should more closely mirror reader is referred to Estabrooks (1998), Nev- the education of children with normal hearing. 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 Parents and the home environment might have idea that the child will generalize what he or the greatest impact on the auditory develop- she learns to other contexts and other targets ment of the child in the early years of implant (Robbins, 1998a). For example, parents might 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, The interested reader is referred to Estabrooks the role of early childhood professionals (1998) and Robbins (1998a) for creative class- 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 The age of implantation might influence the development will depend, to some extent, on type of learning environment most optimal for 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) have suggested that the age of the child plant recipients. A strong-willed child might

260 JEI, 2000, 23:4

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. balk at having to wear the device or might been the focus of a heated debate. This contro- remove the transmitting coil. Educators and versy is beyond the scope of this paper. It is clinicians can assist parents by discussing important, however, that early childhood edu- with them some strategies to help with the use cators are aware of this debate. Specifically, of the device. Rewarding the child with stick- some experts who work with children with co- ers or providing other reinforcements might chlear implants believe that children with co- be effective. When consistent daily routines chlear implants should receive an auditory-ver- and guidelines for device use are established bal education. For more information on the au- early, the child will be more likely to use a ditory-verbal approach, the interested reader is device as he or she gets older. referred to Estabrooks (1994). It is the opinion of the authors that no one Educational Environment and Children communication modality is appropriate for ev- With Cochlear Implants ery child. It is important that the child’s needs Since the founding of schools for deaf children and abilities are carefully evaluated to deter- in the United States, the controversy over what mine the suitability of a particular communi- constitutes appropriate educational placement cation system. Successful implant users can be for deaf children has persisted. Deaf children found in oral, auditory-verbal, cued-speech, younger than 3 years of age are likely to re- and total communication (TC) educational en- ceive services through an early intervention vironments. Regardless of the primary com- program, which might provide home-based, munication modality, it is most important that self-contained classroom based, or inclusive the educational program has an aggressive au- classroom-based programs. Deaf children over ditory component. We emphasize this not to the age of 3, however, might be found in a dismiss the value of manual communication, variety of educational settings, using various but to support the parents’ desire that their communication modalities. They can be found child acquires verbal language. A cochlear im- in residential programs, special day classes, re- plant in itself is not sufficient to make the child source rooms, and inclusive classrooms. Al- an oral communicator. It is the responsibility though inclusion has been the dominant trend of the early childhood professionals to support in the broader special education field, wide- parents in their decision to teach their child spread segregation of deaf children into special verbal language by providing an educational classes and schools has been maintained environment rich with auditory stimulation. A throughout the 1990s. It is likely that the use strong auditory emphasis is most often char- of cochlear implants in young children will fa- acteristic of oral, auditory-verbal, and cued- cilitate the trend towards inclusion in the field speech programs, but tends to be less apparent of deaf education. The enhanced speech and in TC programs. This is not to say that a TC English language skills afforded by a cochlear environment is no longer appropriate once a implant should better equip deaf children for child receives an implant. On the contrary, placement in mainstream settings. As the age children with cochlear implants do not become of implantation becomes lower, it is likely that oral communicators overnight. Continued use deaf children with cochlear implants will be- of a TC approach might be the most effective come more common place in typical commu- means for facilitating language growth in a nity preschools and child care settings. In these child with a cochlear implant. Nonetheless, it early childhood settings, deaf children with co- is essential that the child be exposed to an en- chlear implants will have the advantage of an riched auditory environment as many hours a enriched auditory language environment and day as possible. There is a great need for a proficient peer speech models. strong commitment to maximize the auditory Children with cochlear implants throughout component within a TC approach. In addition, the world might use a variety of different it might be necessary for the school staff to modes of communication. The communication adjust their expectation and teaching priorities, modality used to educate deaf children has long especially if manual communication is the fo-

McKinley & Warren 261

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. cus of the child’s current educational place- Clark, G. M., Cowen, R. S., & Dowell, R. C. ment. (1997). Cochlear implantation for infants and children. San Diego, CA: Singular Publishing. Because simultaneous speaking and signing is difficult, many parents and teachers who Engen, E., & Engen, T. (1983). Rhode Island Test of Language Structure. Baltimore: University sign, speak to deaf children with a weak voice Park. or no voice at all (Nevins & Chute, 1996). To Ertmer, D. J., Kirk, K. I., Sehgal, S. T., Riley, A. enhance the auditory environment, parents and I., & Osberger, M. J., (1997). A comparison of teachers should be encouraged to use their full vowel production by children with multichan- voices when signing to the child. In addition, nel cochlear implants or tactile aids. Ear and it is important that the child engages in verbal Hearing, 18, 307–315. communication as much as possible. The child Estabrooks, W. (1994). Auditory Verbal Therapy for must be motivated to communicate verbally. Parents and Professionals. Washington, DC: Alexander Graham Bell Association for the This might initially involve getting the child’s Deaf. attention, establishing understanding, and cor- Estabrooks, W. (1998). Cochlear implants for kids. recting communication breakdowns. Washington, DC: Alexander Graham Bell As- sociation for the Deaf. Conclusion Geers, A. E. (1997). Comparing implants with hear- By bypassing the damage in the inner ear and ing aids in profoundly deaf children. Otolar- stimulating the auditory nerve directly, cochle- yngology Head and Neck Surgery, 117, 150– ar implants have augmented the auditory ca- 154. pabilities of children with profound sensorineu- Geers, A. E., & Moog, J. S. (1994). Spoken lan- ral deafness. Research has indicated that chil- guage results: Vocabulary syntax, and communication. Volta Review, 96. 131–148. dren with cochlear implants have superior Geers, A. E., & Tobey, E. A. (1995) Longitudinal speech perception, speech production, and lan- comparison of the benefits of cochlear implants guage skills compared to their peers without and tactile aids in a controlled education set- cochlear implants. Although empirical data are ting. Annals of Otology, Rhinology, and Lar- not yet available, anecdotal reports indicate that yngology, 166 (Suppl.), 328–329. cochlear implants might also promote reading Hart, B., & Risly, T. R. (1995). Meaningful differ- achievement, academic success, and social ad- ences in the everyday experience of young Amer- justment in children with prelingual deafness. ican children. Baltimore: Paul H. Brookes. By maintaining a communicative link with the Hasenstab, M. S., & Tobey, E. A. (1991). Language development in children receiving Nucleaus implant center, using naturalistic and meaning- multichannel cochlear implant. Ear and Hear- ful teaching techniques, supporting parental ef- ing, 12, 55–65. forts, and providing an enriched auditory en- Henderson, D., Salvi, R. J., Boettcher, F. A., and vironment, early childhood educators and prac- Clock, A. E. (1994). Neurophysiology corre- titioners can make significant contributions to lates of sensory-neural hearing loss. In J. Katz the success of a young child with a cochlear (Ed.) Handbook of clinical audiology (4th ed.). implant. Baltimore: Williams and Wilkens. Lane, H., & Bahan, B. (1998). Ethics of cochlear implantation in young children: A review and REFERENCES reply from a Deaf-World perspective. Otolar- Balkany, T. (1993). A brief perspective on cochlear yngology Head and Neck Surgery, 119, 297– implants. New England Journal of Medicine, 308. 328, 281–282. Meyer, T. A., Svirsky, M. A., Kirk, K. I., Miyamoto, Bonn, D. (1998). Tune in early for best results with R. T. (1998). Improvements in speech percep- a cochlear implant. Lancet, 352, 1836. tion by children with profound prelingual hear- Carney, A. E., Osberger, M. J., Carney, E., Robbins, ing loss. Effects of device communication A. M., Renshaw, J., & Miyamoto, R. J. (1993). mode and chronological age. Journal of A comparison of speech discrimination with Speech, Hearing, and Language Research, 41, cochlear implants and tactile aids. Journal of 846–855. the Acoustical Society of America, 94, 2096– Miyamoto, R. T., Kirk, K. I., Svirsky, M. A., & 2049. Sehgal, S. T. (1999). Communication skills in

262 JEI, 2000, 23:4

Downloaded from http://jei.sagepub.com by M Peterson on May 28, 2008 © 2000 Division for Early Childhood of the Council for Exceptional Children. All rights reserved. Not for commercial use or unauthorized distribution. pediatric cochlear implant recipients. Acta Oto- Ertmer, D. (1995). Speech intelligibility of im- laryngologia, 119, 219–224. planted children. Annals of Otology, Rhinology, Miyamoto, R. T., Kirk, K. I., Todd, S. L., Robbins, and Laryngology, 166 (Suppl.), 399–401. A. M., & Osberger, M. J. (1995). Speech per- Scarborough, H. S. (1990). Index of Productive ception skills of children with multichannel co- Syntax. Applied Psycholinguistics, 11, 1–22. chlear hearing aids or hearing aids. Annals of Spencer, L. J., Tye-Murray, N., & Tomblin, J. B. Otology, Rhinology, & Larynogology, 166 (1998). The production of English inﬂectional (Suppl.), 334–337. morphology, speech production and listening Miyamoto, R. T., Osberger, M. J., Todd, S. L., Rob- performance in children with cochlear im- bins, A. M., Stroer, B. S., Zimmerman-Phillips, plants. Ear and Hearing, 19, 310–308. S., & Carney, A. E. (1994). Variables affecting Strojny, L., Harrison, J, & Zimmerman-Phillips, S. implant performance in children. Laryngo- (1998). Making the Connection: The school, scope, 104, 1120–1124. implant center, and family. Loud and Clear, Miyamoto, R. T., Robbins, A. M., Osberger, M. J., 1(3), 1–4. Riley, A. I., & Kirk, K. I. (1995). Comparison Svirsky, M. A., & Meyer, T. A. (1999). Comparison of multichannel tactile aids and multichannel of speech perception in pediatric Clarion co- cochlear implants in children with profound chlear implant and hearing aid users. Annals of hearing impairments. American Journal of Otology, Rhinology, and Laryngology, 177 Otology, 16, 8–13. (Suppl.), 104–109. Miyamoto, R. T., Svirsky, M. A., Kirk, K. I., Rob- Tomblin, B. J., Spencer, L., Flock, S., Tyler, R., & bins, A. M., Todd, S., & Riley, A. (1997). Gantz, B. (1999). A comparison of language Speech intelligibility of children with multi- achievement in children with cochlear implants channel cochlear implants. American Journal and children using hearing aids. Journal of of Otology, Rhinology, and Laryngology, 106, Speech, Language, and Hearing Research, 42, 35–36. 497–511. Miyamoto, R. T., Svirsky, M. A., & Robbins, A. M. Tye-Murray, N., Spencer, L., & Woodworth, G. G. (1997). Enhancement of expressive language in (1995). Acquisition of speech by children who prelingually deaf children with cochlear im- have prolonged cochlear implant experience. plants. Acta Otolaryngology, 117, 154–157. Journal of Speech and Hearing Research, 38, Nevins, M. E., & Chute, P. M. (1995). Success of 327–337. children with cochlear implants in mainstream Vermeulen, A. M, Beijk, C. M., Brokx, J. P., van educational settings. Annals of Otology, Rhi- den Borne, S., & van den Broek, P. (1995). De- nology, and Laryngology, 166 (Suppl.), 100– velopment of speech perception abilities of pro- 102. foundly deaf children: A comparison between Nevins, M. E., & Chute, P. M. (1996). Children children with cochlear implants and those with with cochlear implants in educational settings. conventional hearing aids. Annals of Otology, London: Singular Publishing. Rhinology, and Laryngology, 166 (Suppl.), Osberger, M. J., Fisher, L., Zimmerman-Phillips, S., 215–217. Geier, L., & Barker, M. J. (1998). Speech rec- Yoder, P. J., & Warren, S. F. (1998). Maternal res- ognition performance of older children with co- ponsivity predicts the prelinguistic communi- chlear implants. The American Journal of Otol- cation intervention that facilitates generalized ogy, 19, 152–157. intentional communication. Journal of Speech Osberger, M. J., Maso, M., & Sam, L. K. (1993). and Hearing Research, 41, 1207–1219. Speech intelligibility of children with cochlear implants, tactile aids, or hearing aids. Journal of Speech and Hearing Research, 36, 186–203. Ann M. McKinley, Vanderbilt Bill Wilkerson Center Radcliffe, D. (1999). As implant technology ad- for Otolaryngology and Communicative Sciences; vances, number of potential candidates grows. Steven F. Warren, Institute for Life Span Studies. The Hearing Journal, 52(5), 23–31. The authors would like to thank Anne Marie Tharpe for her constructive comments on the preparation Robbins, A. M. (1998a, April). Two paths of au- of this manuscript. ditory development for children with cochlear implants. Loud and Clear, 1(1), 1–4. Robbins, A. M. (1998b, June). Two paths of audi- Address correspondence to Ann M. McKinley, tory development for children with cochlear Vanderbilt University, 1114 19th Avenue South, implants. Loud and Clear, 1(2), 1–4. Nashville, Tennessee 37212. E-mail: ann.m. Robbins, A. M., Kirk, K. I., Osberger, M. J., & [email protected]

McKinley & Warren 263