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Cochlear Implants: Optimizing Patient Benefit through Team Management

and Family-Based Aural Rehabilitation -Author: , M.A. Aud.,

M.S. Com. Dis. Lic. Aud., Cert. Auditory-Verbal Therapist, HEAR In

Dallas, Director Dated: 2/23/2004

Introduction

The professional staff of Dallas Otolaryngology Associates and HEAR In

Dallas joined forces to form the Dallas Otolaryngology Associates

Cochlear Implant (DOA-CI) Team. Together they provide assessment and

treatment to patients seeking cochlear implantation. The team maintains

one philosophical goal-- the maximal use of sound for verbal

communication and environmental monitoring for deaf patients ranging in

age from infants to seniors. It is the team’s philosophy that meaningful

use of sound can enhance the quality of life for almost every deaf

person.

The DOA-CI team includes the following: patient and their family

members, a neurotologist, four audiologists, a nurse,

billing/reimbursement people, two secretaries, a neuropsychologist, a

rehabilitative audiologist/Certified Auditory-Verbal Therapist, two

speech-language pathologists, an occupational therapist and the

administrator of the Dallas Hearing Foundation. Other consultants and

therapists are involved as dictated by individual patient needs. The

team members pool their expertise to form long-term management programs

for patients of all ages.

Upon conclusion of the initial audiometric evaluation, the audiologist

recommends one of three options:

1. The patient participates in a program of aural rehabilitation

with his/her current hearing aids. Patients referred for aural

rehabilitation with hearing aids are monitored: their hearing aid

progress is compared to the outcome anticipated with appropriate

cochlear implantation and aural rehabilitation.

2. The patient tries new hearing aids, participates in short-term

aural rehabilitation and is re-evaluated for implant candidacy as

needed.

3. The patient proceeds with a full evaluation to determine

cochlear implant candidacy and appropriate post-implant aural

rehabilitation.

Implant centers vary greatly in the criteria used to determine patient

candidacy for cochlear implantation. Consistent with their view of

hearing as important for quality of life, the DOA-CI team views the

implant as a tool that provides a range of benefit to patients.

Long-term outcome or benefit from a cochlear implant is impacted by

numerous variables. In determining patient candidacy for implantation

and expected benefit, the team attempts to ascertain patient variables

likely to impact their meaningful use of sound with an implant.

Significant factors include the patient’s age, health, hearing history,

hearing technology history, speech/language/reading/writing status,

communication mode of patient/family/peers, psychological status,

neurological/cognitive status, patient knowledge/goals for CI,

educational options, motivation/compliance, support for developing

auditory behavior, results of trial therapy, finances, time/availability

and distance from the treatment program. Each of these is examined to

formulate a complete picture of the patient and their life. This

information is used to (a) determine candidacy for implantation, (

counsel the patient and family members regarding expected benefit, ©

address issues that would need to change in order to proceed with

implantation, (d) discuss how each issue would impact performance with

the device and (e) explore options for optimizing benefit.

One key factor that leads to patient satisfaction is the free flow of

communication among CI team members. Each member of the team recognizes

and respects the expertise of the other team members and all regularly

exchange information. The physician considers the opinion of each team

member when deciding whether or not to proceed with surgery. The

programming audiologists rely on feedback from the aural rehabilitation

team regarding the patients’ performance with each MAP on speech

perception tasks. The insurance person requests progress reports to

ensure continued coverage of needed services. The neuropsychologist

assesses and treats patients for special learning needs and assists the

team and patients with issues that may arise. Family members share

situations and concerns about the patient’s use of hearing and speech in

daily life: these are used to individualize the aural rehabilitation

program as well as modify the programming of the device. All members of

the team work closely together for optimal care of each patient.

CI Patient Categories

With their broad criteria for candidacy, the CI Team assesses patients

from the following categories:

* Infants identified with sensorineural (SN) hearing loss in the

newborn nursery, toddlers and preschool-aged children identified with SN

hearing loss: these patients are fitted with hearing aids, enrolled in

Auditory-Verbal therapy and family education and response to hearing

aids is monitored and compared to the expected benefit from

implantation.

* Elementary school children and teens from mainstreamed, oral, or

signing programs, with or without intelligible speech: some are referred

for a trial period of aural rehabilitation with hearing aids in order to

assess the child and significant family factors that impact candidacy.

* Young adults and middle-aged adults who have congenital or

peri-linguistic deafness: patients may or may not have experience with

hearing aids, and may or may not have intelligible speech. Patients may

use speech, sign language or a combination of speech and sign for

communication.

* Post-linguistically deafened children from mainstreamed, oral,

or signing programs, with or without intelligible speech

* Post-linguistically deafened adults with short or long-standing

deafness

* Senior citizens with progressive hearing loss who receive

limited benefit from hearing aids

Etiologies & Associated Disorders (s, 2000)

With broadened cochlear implant candidacy criteria, there is an

increased incidence of associated disorders in cochlear implant

patients. Associated disorders can have serious impact on the patient’s

ability to process the signal provided by the cochlear implant; they

also have significant implications on the individual’s potential to

learn to speak. Some examples of etiologies and associated communication

disorders are presented below.

1. Congenital syndromes include CHARGE, CMV, rubella, cerebral

palsy, Usher syndrome, fetal alcohol syndrome.

2. Acquired neonatal and childhood disorders include prematurity,

hyperbilirubinemia, ECMO, meningitis, ototoxicity.

3. Developmental disorders of unknown etiology that co-occur with

hearing loss includes sensory processing and sensory integrative

disorders, feeding disorders, autism, auditory neuropathy, dyspraxia,

cognitive delay/differences, attention deficits, language and learning

differences, gross/fine motor delays, psycho-social differences and

others.

Working with people who have associated disorders requires awareness,

knowledge, experience; early involvement of team members; vigilance

regarding medical and audiologic concerns; ongoing monitoring; realistic

expectations from cochlear implantation; a high degree of

parental/familial support and flexibility.

There are four concepts the team identifies as ''key'' when considering

implantation of a patient with multiple disorders. They are:

1. Plasticity - The capacity to be pliable, reshaped, molded as new

stimuli arrives and is internalized.

2. Adaptation/Generalization - The ability to modify

response/behavior to changing conditions.

3. Compensation – The ability to offset deficit areas through

maximal development of less impaired function.

4. Integration – The ability to bring together or incorporate

separate parts into a unified, harmonious, and interrelated whole.

These concepts are used in family counseling and when designing the

rehabilitation program.

Establishing Auditory Processes for Comprehension of Spoken Language and

for Acquisition and Self-Monitoring of Speech Production

Post-linguistically deafened adults are typically seen for short-term

aural rehabilitation. Since they already possess the cognitive processes

of audition and the motor skills of speech, rehabilitation typically

consists of counseling and adjustment issues and auditory training.

Family members are included in therapy and are taught to administer home

program assignments to support the patient’s auditory development.

Many CI patients are pre-linguistically deaf. For this group of children

and adults, a significant portion of therapy time is devoted to

developing listening skills for the comprehension of spoken language as

well as an auditory feedback system to guide the use of the three

subsystems of speech (Pollack, 1985[a]). Learning to listen unfolds

quite naturally for neurologically-intact children who are implanted

within the first few years of life and managed in an Auditory-Verbal

program. Therapy for this group incorporates parent education, whereby

the parent learns to foster the child’s natural patterns of audition and

spoken language development (, 2000, Samson, 1994) throughout

daily interactions.

For pre-linguistically deafened adults, the development of auditory

processes is an arduous task following activation of a cochlear implant.

Brain functions associated with hearing develop slowly in adults who

have been deaf since birth. These individuals did not have the

opportunity to develop the cognitive processes based on audition for

receptive and expressive verbal language. Neither did they learn the

respiratory, phonatory and articulatory functions for the production of

intelligible speech (Hudgins and Numbers, 1942). Pre-linguistically

deafened adults who begin hearing in adulthood must learn to perceive

the prosodic and segmental aspects of their own speech and must learn to

correct their own atypical speech habits as they learn to produce more

appropriate speech sounds and patterns.

With a cochlear implant, children and adults must learn to process sound

and develop meaningful use of acoustic input. Some of the cognitive

processes that result in meaningful use of sound are as follows:

attention to sound through time, the ability to judge two sounds as same

or different, auditory imagery and memory for auditory images, memory

span for auditory events, maintenance of the sound sequences,

associating sounds with their referents, use of sound for linguistic

purposes and retrieval of sound images for linguistic expression

(, et. al., 1999, Pisoni and Geers, 1998, Baddeley and Logie,

1992, Pollack, 1985(a), Erber, 1982). Aural rehabilitation focuses on

developing these skills in the patient and assisting family members in

supporting the use of these functions in daily experiences.

In addition to using hearing for language comprehension, audition is the

key sense through which individuals with normal hearing monitor their

speech. From the first few months of life forward, infants proceed

through cooing, vocal play, babbling, jargon and phonological maturation

on their journey toward intelligible speech. Hearing is the primary

sense that weaves the motor and tactile/kinesthetic aspects of the

mother tongue into the child’s developing sensory/motor system. Through

audition, children experience the sounds produced by the three

sub-systems of speech—respiration, phonation, and articulation. This

auditory feedback system guides the infant in making necessary

modifications in production for integrating the complex functions of the

three subsystems of speech. Over time, automaticity of movement of the

muscles of all three subsystems is achieved resulting in intelligible

speech. Below are some aspects of speech that patients need to learn to

control speech production through hearing (Ling, 2002).

Respiration: gaining control over the muscles involved in breathing for

* Use of the breath in sustained phonation, build up oral pressure

for plosives and fricatives, differentiation of voiced and voiceless

sounds, modification of vocal loudness, and production of syllable

strings for multisyllabic words, phrases and sentences.

Phonation: gaining control over the laryngeal muscles for

* Production of vowels, voiced and voiceless consonants.

* Vocal pitch that is appropriate to patient’s age/sex, linguistic

uses of pitch for speaking prosody, singing.

* Voice quality.

Articulation: gaining control over the musculature of the lips, tongue,

jaw and velopharynx for

* Vowels: front/back, high/low:

* Requires proper movement of the lips, jaw, velopharynx,

tongue tip, and middle and back portions of the tongue.

* Consonants: stops, nasals, glides, plosives, fricatives,

affricates:

* Requires complex control and coordination of all three

subsystems of speech production.

* Sequences of consonants and vowels:

* Requires smooth movements between vowels and consonants

in repeated syllable production and alternated syllable production.

* Requires complex interactions of refined functions of

all three subsystems.

Sensory Processing Disorders and Sensory Integration Dysfunction

Proper use and integration of information received by the brain from the

various senses impacts a child’s ability to learn (Kranowitz, 1998). The

integration of sensory information from hearing, sight and touch is

essential for meaningful use of the signal provided by hearing

technologies.

Many children with hearing loss (, 1988) have atypical sensory

processing and integrative functions that lead to a host of atypical

behaviors. Among these are delays in gross and fine motor development,

increase in self-stimulatory behaviors, poor eye contact, poor social

interactions, feeding difficulties, sleeping problems, slow or

disordered speech, language and learning disabilities and differences,

and academic problems.

Sensory processing deficits require specialized forms of therapy to

facilitate more typical use and integration of sensory information

(Kranowitz, 1998). Some occupational therapists specialize in treating

sensory integration dysfunction to help the child process and coordinate

sensory input in order to learn more efficiently.

Characteristics of Deaf Children that may Indicate Sensory Processing

Dysfunction

Many hearing impaired and deaf children exhibit sensory processing

dysfunction as described by Kranowitz (1998). This may include

over-sensitivity or under-sensitivity to touch, sight, movement, sound,

smell and/or taste as well as poor integration of the sensory/motor

systems. Children with sensory processing dysfunction may have delayed

development in the areas of cognition, gross and fine motor skills,

muscle tone and psycho/social interaction.

Sensory integration therapy helps children organize information entering

the brain through the various senses. Sensory integration therapy can

improve the child’s ability to learn motor behaviors, speech/language

and academic information. With appropriate therapy, children may improve

their eating, playing and social behaviors as well. The purpose of

sensory integration therapy is to help the child achieve and maintain an

optimal state for learning, thereby developing at the fastest rate

possible within the parameters of their physical and cognitive

abilities. Outcomes vary from child to child and are influenced by the

severity of the dysfunction of the particular child, the child’s

cognitive level, and environmental factors.

Kranowitz (1998) described treatment activities to improve body

awareness, postural security, tactile discrimination, tactile

defensiveness, balance, bilateral coordination, motor planning/movement

sequences, fine motor skills, extension against gravity, flexion, ocular

control and visual-spatial perception.

Educational Component of the Aural Rehabilitation Program

In working toward the goal of communicative competence and communicative

independence, the aural rehabilitation staff on the DOA-CI team provides

direct therapy to the patient and counsels parents regarding educational

programs that support the child’s use of hearing and spoken language.

Parents are advised how to work with their school district to develop an

Individualized Education Plan (IEP) that integrates the child’s aural

rehabilitation needs into the services provided by the school. The

therapists find it useful to review the child’s IEP and write goals for

the parents to submit to the IEP committee. The goal of sharing

information with the school staff is to create a maximal auditory

learning environment throughout the school day. IEP goals typically

address the child’s need for classroom instruction via spoken language

as well as increased opportunities for the child to practice speaking

and interacting with hearing peers.

The educational and communicative limits imposed by an emphasis on sign

language have been documented (COED, 1988). Most significant is that

some ninety percent of children with hearing impairment are born to

parents with normal hearing and the normal hearing parents rarely know

or develop proficiency in sign language. Nonetheless, deaf education

programs in the public schools usually teach signed rather than spoken

language. This protocol results in a low proficiency in written or

spoken English, an average reading level of third grade upon graduation,

and a situation in which sixty percent of the graduates have a lifetime

of unemployment or severe under-employment (COED, 1988).

Fortunately, new aural rehabilitation management procedures have raised

the academic achievement levels of many deaf children -- even before the

advent of cochlear implants (Goldberg and Flexer, 1993). With the

fitting of hearing aids on young children several decades ago, a number

of individuals have developed aural rehabilitative procedures that

foster the use of audition for spoken language in severely and

profoundly deaf children. Stunningly, the results reported in their 1993

study were obtained on children who (essentially) preceded the cochlear

implant era.

These procedures are now referred to as ''Auditory-Verbal'' (AV)

management (AVI, 1993) and are applied to children at some CI centers

( and Sowers, in prep). The results are in sharp contrast to those

obtained by the Commission on Education of the Deaf, who studied

traditional deaf education programs (COED, 1988).

Goldberg and Flexer studied the long-term outcomes of 152 graduates of

Auditory-Verbal programs throughout North America. Ninety-three percent

of the subjects had severe-profound hearing impairment and were fitted

with hearing aids at an average age of 23 months. 36.7% reported

associated disorders in addition to their deafness. Respondents received

an average of 11 years of AV therapy and parent education. None of the

152 had the benefit of a cochlear implant.

Outcomes for this group included the following: 70% graduated from

regular high school between 16 and 18 years of age, over 75% of the

subjects were fully mainstreamed in regular classrooms and 95% received

education after high school with 88% attending colleges and universities

for hearing students. All but one subject reported significant

involvement of a mother in the rehabilitation process; 80% reported

active participation of a father and 67% reported sibling involvement in

their rehabilitation process. Seventy-eight percent used the telephone

to send and receive messages and 49% used a telecommunications device

for the deaf. Over half of the respondents reported early and continued

involvement in community activities including scouting,

churches/synagogues, clubs, sports, sororities, fraternities, etc. One

individual reported self-perception as part of the Deaf community, 27%

perceived themselves as part of the hearing mainstream and Deaf

community and 73% perceived themselves as part of the hearing mainstream

only. The AV program graduates entered careers of their choices

including administrative assistant, computer programmer, finance

manager, bank vice-president, truck driver, graphic artist courier,

painter, social worker, engineers, teachers, attorneys, dentist,

physician, etc.

Principles of Auditory-Verbal Management

Auditory-Verbal management is a form of aural rehabilitation that

develops hearing as the foundation for verbal language learning

(Estabrooks, 1994). It is strongly rooted in parent participation and

the creation of an auditory learning environment at home and school.

Individual patient needs dictate modifications of therapy goals and

procedures. The therapist’s individual areas of expertise, personality,

mentor and interests guide the selection of therapy activities. Although

specific techniques and procedures used in auditory-verbal development

vary from one Auditory-Verbal therapist to another, the learning

principles followed are consistent with those described in the cognitive

sciences (Neisser, 1987).

Regardless of these differences, Auditory-Verbal therapists maintain the

same guiding principles in their management of the child and family. The

general concepts of audition as the driving sensory modality, verbal

communication as the teaching tool and goal, and modification of the

environment for auditory learning provide the consistency among

professionals within AV. Below is an outline of the ''ACE'' concept of

AV management ( et. al., 1993)—audition as the basis for

communication and environment.

AUDITION

* Support early diagnosis of the hearing impairment and hearing

technology for optimal access to the acoustic speech spectrum

* Develop speech and environmental interactions through hearing

* Maintain use of hearing technology throughout the patient’s

waking hours

COMMUNICATION

* Develop a family-therapist partnership

* Promote spoken language as the primary means of communication

* Evaluate and monitor progress and treatment plan on an ongoing

basis

* Guide the patient through normal stages of hearing, speech and

language development

* Individualize therapy

ENVIRONMENT

* Maintain/foster a normal living environment within the

hearing/speaking society

* Teach family members to create an auditory learning environment

in daily living

* Facilitate independent functioning in the educational and

employment mainstreaming

* communication with typical, hearing/speaking peers and

social groups

* Encourage auditory activities such as music and dance lessons,

use of CD players, etc.

Conclusion

With the vastly heterogeneous population implanted at the DOA-CI center,

management by a team of specialists is essential for optimizing patient

benefit from a cochlear implant. In addition to the expertise offered by

the professional staff, the patient and members of the patient’s family

play a critical role in optimizing benefit: they do so by maintaining an

auditory learning environment at home, fulfilling the home program goals

and updating the staff on patient performance in daily living. Although

individual performance outcomes vary widely from patient to patient,

satisfaction with the device is generally high due to the extensive

assessment and family counseling program. As stated earlier, the

professional cochlear implant team maintains one philosophical goal —

the maximal use of sound for verbal communication and environmental

monitoring. The team continues to pursue their goal of enhancing the

quality of life for deaf individuals who want to hear.

References

Baddeley, A., and Logie, R., 1992, Auditory Imagery and Working Memory,

In Reisberg, D., Ed., Auditory Imagery, Lawrence Erlbaum Assoiciates,

Publ., Hillsdale New Jersey.

The Commission on Education of the Deaf, February 1988, Toward Equality:

Education of the Deaf, A Report to the President and the Congress of the

United States.

, L., in prep, DDOVS: A Rating Scale for Auditory-Verbal

Competence. Monograph on Cochlear Implants. Graham Bell

Association for the Deaf.

, L., 2003, Cochlear Implants Across the Lifespan: Assessment,

Candidacy, Treatment and Outcomes, A Short Course Presented to the Texas

Academy of Audiology, November 14, College Station, Texas

, L., 2000, MotherSong: Natural Language For Auditory-Verbal

Development. The Listener. Journal of the Learning to Listen Foundation.

Summer, Toronto, Canada.

, L., 1988-2003, Clinical notes of observations of deaf children

who have cochlear implants.

, L., Ernst, M., Rothwell-Vivian, K., 1998, adapted from:

Auditory-Verbal International, 1993, AVI Principles and Rules of Ethics.

, L., Daniloff, D., and Schuckers, G., 1999, ALPS: A Language

Rehabilitation Program for Children with Cochlear Implants, The Journal

of Louisiana Applied Health Professionals, Vol. II, Summer.

, L. and Sowers, J., in prep. Dallas Otolaryngology Associates and

HEAR in Dallas: ''The Heart of Hearing Team''.

Estabrooks, W., 1994, Ed., In Auditory-Verbal Therapy for Parents and

Professionals, Graham Bell Association for the Deaf, Wash.

D.C.

Erber, N., 1982, Auditory Training, Graham Bell Association

for the Deaf, Wash. D.C.

Goldberg, D. and Flexer, C., 1993, Outcome Survey of Auditory-Verbal

Graduates: Study of Clinical Efficacy, Journal of the American Academy

of Audiology, 4, pp.189-200.

Hudgins, C. V. & Numbers, F. C., 1942, An Investigation of

Intelligibility of Speech of the Deaf. Genetic Psychology Monograph, 25,

289-392.

Kranowitz, C., 1998, The Out-of-Sync Child: Recognizing and Coping with

Sensory Integration Dysfunction, Perigee Publishers.

Ling, D., 2002, Speech and the Hearing-Impaired Child: Theory and

Practice, 2nd Ed., Graham Bell Association for the Deaf, Wash.

D.C.

Neisser, J.U., 1987, From Direct Perception to Conceptual Structure. In

Neisser, U., ed. Concepts and Conceptual Development: Ecological and

Intellectual Factors in Categorization. Cambridge, Cambridge University

Press.

s, R., 2000, Hearing Loss and Associated Disorders, Seminar in

Auditory-Verbal Development and Cochlear Implantation, Dallas, Texas.

Pisoni, D. B. and Geers, A., 1998, Working Memory in Deaf Children with

Cochlear Implants: Correlation Between Digit Span and Measures of Spoken

Language Processing. Paper presented at the 7th Symposium on Cochlear

Implants in Children, Iowa City, IA, June 4-6.

Pollack (a), D., 1985, Educational Audiology for the Limited Hearing

Infant and Preschooler, 132-160, Chas. C. , Publ., Springfield,

Illinois.

Pollack (, D., 1985, Educational Audiology for the Limited Hearing

Infant and Preschooler, 161-196, Chas. C. , Publ., Springfield,

Illinois.

Samson, A. B., 1994, The Family-Professional Partnership: A Parent

Perspective, In Auditory-Verbal Therapy for Parents and Professionals,

Estabrooks, W., Ed., 195-215, Graham Bell Association for the

Deaf, Wash. D.C.

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