Professional Documents
Culture Documents
Rehabilitation and Educational Considerations For Children With Cochlear Implants
Rehabilitation and Educational Considerations For Children With Cochlear Implants
Educational
Considerations for
C h i l d ren w i t h
Cochlear Implants
Uma G. Soman, MED, LSLS Cert AVEda, Dana Kan, MA, NBCT
a
,
Anne Marie Tharpe, PhDa,b,*
KEYWORDS
Rehabilitation Education Cochlear implants
Pediatric deafness
Cochlear implants improve numerous outcomes for children with hearing loss. They
make spoken language a viable communication option for those with severe-to-
profound losses,1 improve speech perception2,3 and speech production skills,4 and
contribute to improved reading outcomes for school-aged students.5 Moreover, the
use of cochlear implants increases the likelihood that children with hearing loss can
be included in general education settings.6 These findings are encouraging; however,
the device is rarely the sole contributor to these positive outcomes. Systematic reha-
bilitation and educational programming are necessary for cochlear implant recipients
to reach their full potential.7
This article focuses on rehabilitation and educational considerations for children
with cochlear implants. Although distinctly different, the goals of rehabilitation and
education overlap considerably in good practice. The term rehabilitation is typically
used to refer to an individualized model of therapy, such as one-on-one training
The roots of deaf education date back to the early sixteenth century in Western Europe.
However, it was not until the nineteenth century that deaf education came to the United
States. Thomas Hopkins Gallaudet, a graduate of Yale University and an ordained
minister, helped establish the first permanent school for the deaf in 1817. Now called
The American School for the Deaf, the institute’s first teacher was a deaf man Gallaudet
met while studying manual education methods in France. This teacher, Laurent Clerc,
is credited with the development of American Sign Language (ASL) and was respon-
sible for training many of the first teachers of the deaf. Fifty years later, oral education
was introduced. These programs were designed for children who were adventitiously,
and postlingually, deafened. Shortly after World War II, transistors were invented,
which greatly reduced the size of hearing aids. This miniaturization of hearing aids
permitted more practical use of the devices, especially in children. As amplification
devices became more sophisticated, oral communication expanded to children who
were congenitally deaf. Educational recommendations were subsequently based on
degree of hearing loss. Children with adequate residual hearing were considered
candidates for the oral approach; manual education programs were recommended
for children with limited residual hearing. However, approval of the use of cochlear
implants in children in the 1990s expanded the option of oral communication to those
with profound hearing loss. Today, children with diverse types and degrees of hearing
loss are served by a wide variety of educational approaches.
Historically, the educational program chosen for children with hearing loss has been
linked with their communication modality. Although the dichotomy of spoken (oral)
versus signed (manual) language is predominant, there are a variety of communication
modalities that span across a continuum:
1. ASL. ASL is often referred to as the language of the Deaf community (ie, people
who affiliate themselves with deaf culture). It is a rich and vibrant language,
complete with unique syntactical and morphologic elements that are distinct
from English. Deaf children of deaf parents, who receive exposure to ASL from
infancy, develop linguistic competence comparable with hearing children of
hearing parents, albeit not in English.8 ASL is used in residential and day schools
for the deaf, as well as in classrooms located in both public and private institutions.
2. Total communication (TC). TC refers to a diverse group of communication options
that combines manual signs with spoken language. Sign systems, such as Signing
1
An auditory-verbal therapist is a speech-language pathologist, audiologist, or teacher of the deaf
who specializes in teaching children with hearing loss to develop spoken language through the
development of audition. The auditory-verbal therapist also guides and coaches the family. The
Alexander Graham Bell Academy for Listening and Spoken Language oversees the certification of
auditory-verbal therapists.
Rehabilitation for Children with Cochlear Implants 143
Exact English (SEE) and pidgin signs, are typically used because of their compat-
ibility with English word structure. This approach also includes the bilingual-
bicultural method, which treats English instruction as a second language for
students whose first language is ASL.
3. Auditory/oral. Oral communication options rely on amplification and use of residual
hearing to develop audition and spoken language. This modality is used in both
public and private schools, including special schools designed for children with
hearing loss. Cued speech, a visual system used to improve speech reading, is
also in this category.
Although these 3 categories simplify the variety of communication types and educa-
tional programming options available to children with hearing loss, they provide
a framework for the common approaches that have resulted from the selection of
communication modality. These categories are not mutually exclusive; children with
hearing loss might participate in any or all of these programs at various times
throughout their education.
Approximately 90% of children with hearing loss are born to parents who have
normal hearing,9 so the number of parents choosing oral methods for their children’s
education is increasing.10 From the 1999 to 2000 until the 2007 to 2008 school years,
students relying exclusively on spoken language as their primary method of instruction
increased from 44% to 52%.11,12 Moreover, 87% of children with hearing loss are
using some degree of spoken language in educational settings.12
Cochlear implants have allowed the education of students with hearing loss to
follow the national trend toward educating students with disabilities alongside their
typically developing peers. Instead of attending residential schools, children with
hearing loss are increasingly being educated in their neighborhood schools.13 During
the 2007 to 2008 school year, approximately 60% of students with hearing loss were
included in general education classrooms. Regardless of communication modality,
early identification and intervention for hearing loss facilitates the development of
language skills that lead to increased participation in general education classrooms.
Educational Legislation
The education of students with hearing loss is governed by federal legislation. In 1975,
Public Law 94-142, the Education of All Handicapped Children Act, radically changed
the concept of special education. The primary provisions mandated that students with
disabilities receive a free, appropriate, public education; be educated in the least
restrictive environment; and receive an Individualized Education Program (IEP). In
1990, this law was amended by the Individuals with Disabilities Education Act
(IDEA), which was divided into 4 parts14:
A. General provisions
B. Special education services for children and youth
C. Early intervention services for infants and toddlers
D. National activities for improving the education of students with disabilities.
Parts B and C relate directly to educating students with hearing loss.
Part C of IDEA covers infants and toddlers from birth until age 3 years. The provi-
sions are designed to improve long-term outcomes for children with disabilities
through early intervention. The focus of early intervention is to empower families
to meet their children’s developmental needs. Several professionals are involved
in this process, including audiologists who assess the child’s hearing, otologists
who assess the cause of the hearing loss, and early interventionists who provide
144 Soman et al
Several studies have documented the variability of outcomes for children with
cochlear implants.15–17 A cochlear implant, even when provided at a young age,
does not guarantee the acquisition of age-appropriate listening and spoken language
skills, general educational placement, or successful academic and social outcomes.
Some factors that influence outcomes are age of implantation,18 participation in early
intervention,19 and presence of additional disabilities.20 Evidence of the impact of
underlying neurocognitive processes is also emerging.21
A rehabilitation plan developed through collaboration among professionals is
necessary to meet the child’s needs and facilitate desired outcomes. Each of the
professionals involved (the otologist, the audiologist, the speech-language patholo-
gist, and the teacher of the deaf) makes a distinct and essential contribution to the
rehabilitation process. For example, the teacher of the deaf might report a child’s diffi-
culty with auditory discrimination in noise. The audiologist can then create a separate
speech-in-noise program in the implant for use in adverse listening conditions.
Purposeful collaboration at different stages of rehabilitation, including candidacy deci-
sions and periodic evaluation of performance (Table 1), identifies changing needs
expediently, allows for ongoing adaptation of the rehabilitation plan, and helps main-
tain realistic expectations for families.
Rehabilitation for Children with Cochlear Implants 145
The rehabilitation plan should take into account the various mitigating factors
related to:
1. The child receiving the implant
2. The family of the recipient
3. The rehabilitation supports
Reed and colleagues22 identified the unique contributions of each of these factors to
the academic success of children with hearing loss. Each is described later in relation
to the rehabilitation of children with cochlear implants.
by the rehabilitation team before cochlear implantation and throughout the rehabilita-
tion process:
What is the family’s desired outcome for the child?
What are the recommendations for rehabilitation and education?
What types of support are available through the implant center, local early inter-
vention system, and school system?
What resources (physical, social, financial) does the family have to follow these
recommendations?
What is the role of the family in the rehabilitation process?
As noted previously, there is wide variation in outcomes for children who receive
cochlear implants. It is rare, but not impossible, for some children to receive minimal
or no benefit from the implant and the rehabilitation process. However, 87% of parents
report wanting their children to use spoken language to communicate after receiving
an implant.24 Although all the factors influencing outcome variability are not yet fully
understood, professionals have a responsibility to provide parents with appropriate
and adequate information about all potential outcomes.
Rehabilitation Supports
Achievement of desired outcomes requires a rehabilitation plan that meets the needs
of the child and facilitates development of auditory, language (spoken and/or signed),
and academic skills. At a minimum, supports in the following areas should be consid-
ered as necessary supplements to educational intervention:
Audiological management
Access to an implant center is essential to ensure the maintenance of the cochlear
implant. Being far away from an implant center is stressful for parents and can have
a negative impact on the language and academic outcomes of children.25 Experience
suggests that children who have difficulty accessing the services of an implant center
might experience longer periods of time between mapping sessions, spend more days
waiting for equipment to be replaced or serviced, and lose valuable listening time as
a result of damaged or malfunctioning equipment. Although all families cannot be ex-
pected to move their homes to be close to implant centers, it is becoming increasingly
common for cochlear implant programming and troubleshooting to be available via
telehealth options. Implant manufacturers and cochlear implant teams should be
able to advise families of such options.
Speech and language therapy
When the desired outcome of cochlear implantation is to develop listening and spoken
language skills, intensive speech and language therapy is necessary. Although services
differ based on each child’s current level of performance, it is recommended that children
receive auditory-based therapy after implantation to maximize benefit from the cochlear
implant. The speech-language pathologist focuses on developing listening skills to facilitate
language acquisition. The teacher of the deaf complements the speech-language pathol-
ogists by focusing on language through academic development. However, few speech-
language pathologists are currently trained to work with children with hearing loss who
are developing listening and spoken language.26 Thus, the rehabilitation team should
collaborate with the speech-language pathologist and provide information and resources.
Academic services
Teachers of the deaf are trained to develop language skills (spoken or signed) to
support academic instruction and social development. Some teachers of the deaf
Rehabilitation for Children with Cochlear Implants 149
work at one specific school; others are itinerant teachers who serve numerous
students at multiple locations. Because the inclusion of children with hearing loss in
general education classrooms is increasing, teachers of the deaf are often responsible
for collaborating with general education teachers. A factor that contributes to
academic success is the willingness of general education teachers to support the child
with hearing loss, but maintain appropriate academic expectations.22 That is, a general
education teacher should provide the tools for learning (eg, study guides, modified
tests) but expect children to participate to the best of their abilities.
Rehabilitation recommendations
Rehabilitation Recommendations
Rehabilitation services
Work with a teacher of the deaf or speech-language pathologist to develop
listening skills using the new implant and to develop spoken language, in addi-
tion to sign language.
Educational placement and support
Review Marcus’s IEP
- Add new objectives related to listening and spoken language.
hearing peers.
- Continue services with a teacher of the deaf to develop age-appropriate
An important point to consider is that additional disabilities are often diagnosed after
implantation and may warrant a reevaluation of the child’s educational plan.
SUMMARY
Cochlear implants have greatly expanded opportunities for children with profound
hearing loss. The successful outcomes for children who receive cochlear implants
are predicated largely by mindful collaboration between professionals and families.
Professionals working with children who have a hearing loss must be aware that the
definition of success with a cochlear implant is different for each child and each family.
The goal should be to support children and help families achieve their desired
outcomes through the development, implementation, and continuous evaluation of
strong and realistic rehabilitation plans.
REFERENCES
1. Brown C. Early intervention: strategies for public and private sector collaboration.
Presented at the 2006 Convention of the Alexander Graham Bell Association for
the Deaf and Hard of Hearing. Pittsburgh(PA), June 23–27, 2006.
152 Soman et al
21. Pisoni D, Kronenberger W, Roman A, et al. Measures of digit span and verbal
rehearsal speed in deaf children after more than 10 years of cochlear implanta-
tion. Ear Hear 2011;32:60S–74S.
22. Reed S, Antia S, Kreimeyer K. Academic status of deaf and hard-of-hearing
students in public schools: student, home, and service facilitators and detractors.
J Deaf Stud Deaf Educ 2008;13(4):485–502.
23. Antia S, Jones P, Reed S, et al. Academic status and progress of deaf and hard-
of-hearing students in general education classrooms. J Deaf Stud Deaf Educ
2009;14(3):293–311.
24. Hyde M, Punch R, Komesaroff L. Coming to a decision about cochlear implanta-
tion: parents making choices for their deaf children. J Deaf Stud Deaf Educ 2010;
15(2):162–78.
25. Punch R, Hyde M. Children with cochlear implants in Australia: educational
settings, supports, and outcomes. J Deaf Stud Deaf Educ 2010;15(4):405–21.
26. Houston T, Perigoe C. Speech-language pathologists: vital listening and spoken
language professionals. The Volta Review 2010;110(2):219–30.
27. Daneshi A, Hassanzadeh S. Cochlear implantation in prelingually deaf persons
with additional disability. J Laryngol Otol 2007;121(07):635–8.
28. Wiley S, Jahnke M, Meinzen-Derr J, et al. Perceived qualitative benefits of
cochlear implants in children with multi-handicaps. Int J Pediatr Otorhinolaryngol
2005;69(6):791–8.
29. U.S. census bureau, 2005-2009 American community survey. Available at: http://
factfinder.census.gov/servlet/STTable?_bm5y&-geo_id501000US&-qr_name5ACS_
2009_5YR_G00_S1601&-ds_name5ACS_2009_5YR_G00_. Updated September
22, 2009. Accessed April 1, 2011.
30. American Speech-Language-Hearing Association. Demographic profile of ASHA
members providing bilingual and Spanish-language services. Available at: http://
www.asha.org/uploadedFiles/Demographic-Profile-Bilingual-Spanish-Service-
Members.pdf. Updated May, 2010. Accessed April, 2011.
31. Waltzman S, Robbins A, Green J, et al. Second oral language capabilities in chil-
dren with cochlear implants. Otol Neurotol 2003;24:757–63.
32. Robbins A, Green J, Waltzman S. Bilingual oral language proficiency in children
with cochlear implants. Arch Otolaryngol Head Neck Surg 2004;130:644–7.