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