R e h a b i l i t a t i o n an d

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 authors have nothing to disclose.

a
Department of Hearing and Speech Sciences, Vanderbilt University School of Medicine, 1215
21st Avenue South, Room 8310, Nashville, TN 37232-8242, USA
b
Vanderbilt Bill Wilkerson Center, Nashville, TN, USA
* Corresponding author. Department of Hearing and Speech Sciences, Vanderbilt University
School of Medicine, 1215 21st Avenue South, 6308 Medical Center East, Nashville, TN
37232-8718.
E-mail address: [email protected]

Otolaryngol Clin N Am 45 (2012) 141–153

doi:10.1016/j.otc.2011.08.022 oto.theclinics.com
0030-6665/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
142 Soman et al

with a speech-language pathologist or auditory-verbal therapist1; education typically

refers to learning facilitated by a teacher in a school-based environment. Children with
cochlear implants benefit from the intentional collaboration of these 2 practices. For
example, teachers should integrate speech and language goals into academic lessons
and speech-language pathologists should integrate academic content into speech
and language activities. This article uses the terms interchangeably as a reminder of
their ideal interconnectedness.

OVERVIEW OF DEAF EDUCATION

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

family-centered therapy. Similar to an IEP, an Individualized Family Service Plan (IFSP)

is a legal document developed to guide the rehabilitation process for children and their
families. The provisions in part C, along with the rest of IDEA, enable the development
of effective educational plans for children with cochlear implants.
Part B of IDEA addresses school-aged children and youth (aged 3–21 years) and
provides specific guidelines for educational services. Before the mandate of free, appro-
priate, public education, children with hearing loss, as well as those with other 1 excep-
tionalities, were systematically denied access to individualized rehabilitation. The law
does not guarantee services to every child with a disability, or to every child with a hearing
loss. Students must show a need, resulting from the disability, for specialized educational
programming. Although disagreements exist about what constitutes appropriate
services, students with hearing loss often have delayed language skills that negatively
affect their educational performance, thus qualifying them for services under IDEA.
When a child qualifies for services, the educational team develops an IEP based on
the student’s current functioning level. The team is typically composed of a special
educator, a general educator, a local education agency representative, and the
parents/guardians of the child. Other members might include school administrators,
related service providers (eg, speech-language pathologists, audiologists, occupa-
tional therapists, psychologists), and the students themselves. The IEP team makes
numerous educational decisions, including which services are needed, how often
and in which settings the services will be provided, and how progress on selected
goals will be evaluated. The IEP is updated at least annually and serves as a unique
blueprint for each child’s specific educational needs.
An important task for the IEP team is to determine the least restrictive environment
in which rehabilitation should occur. A continuum of possible placements is shown in
Fig. 1. The specific needs of each individual student also need to be considered.
These needs include academic supports (eg, teacher of the deaf, interpreters, hearing
technology) as well as opportunities for socialization. The child’s environment should
be continuously evaluated to reflect the child’s development and to achieve the fam-
ily’s desired outcome.

FACTORS INFLUENCING REHABILITATION AND EDUCATION

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

Fig. 1. Educational placements on a continuum of least restrictive environments. aOften

referred to as mainstreaming. bModifications refer to changes (eg, modified test of listening
comprehension); accommodations refer to supports (eg, assistive listening devices, pre-
teaching of vocabulary). cOften referred to as inclusion.
 146
Soman et al
Table 1
A collaborative model for rehabilitation of cochlear implant recipients

Speech-Language Teacher General Education

Steps in the Rehabilitation Process Parent Otologist Audiologist Pathologist of the Deaf Teacher
1. Determine candidacy for cochlear U U U U U U
implantation
2. Assess physiologic structures/function — U U — — —
for implant compatibility
3. Implant the device and monitor the — U U — — —
internal device function in the
operating room
4. Program the implant for maximum — — U — — —
auditory access
5. Assist with maintenance and U U U U U U
troubleshooting of cochlear implant
6. Develop age-appropriate speech, U — U U U U
language, and auditory skills
7. Develop age-appropriate academic and U — — U U U
social skills
8. Evaluate and monitor progress U U U U U U
9. Develop goals and objectives for U — U U U U
Individualized Education Plan/IFSP
10. Facilitate opportunities for meaningful U — — U U U
interaction with normal-hearing peers
11. Educate parents and other professionals U U U U U U
about cochlear implants
 Rehabilitation for Children with Cochlear Implants 147

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.

Child Receiving the Implant

Rehabilitation teams consider the individual characteristics of the child, especially the
present level of performance on academic, speech-language, and auditory tasks, and
the presence of additional disabilities. Input from all professionals regarding the child’s
abilities before implantation is necessary to develop a plan that builds on the child’s
current level of skills. For example, the rehabilitation plan for a 3-year-old with
profound hearing loss who has limited auditory and language skills should be distinctly
different than that for a 6-year-old who has a progressive hearing loss and age-
appropriate language skills.
The presence of an additional disability adds a new dimension to the rehabilitation
plan. The unique impact of the additional disability on overall development will likely
require the team to develop a plan and establish benchmarks for measuring progress
that are different from the ones used for children with hearing loss only.

Family Involvement and Expectations

Discussion regarding the parents’ desired outcomes after implantation is essential for
setting realistic expectations, planning rehabilitation, and recommending educational
options. For example, the rehabilitation plan for a 12-month-old whose parents want
him to develop listening and spoken language and go to a mainstream school along-
side his hearing peers is vastly different than that for a 12-month-old whose parents
want her to learn spoken English and ASL and be part of the deaf community.
Parental involvement and expectations are positively correlated with academic
achievement. That is, children of parents who have high expectations, maintain
consistent communication with the school, help with homework, and enroll their chil-
dren in extracurricular activities have better academic outcomes.22,23 Educating
parents to be active participants in the rehabilitation process is critical to their chil-
dren’s successful use of cochlear implants. Typically, parents of children with cochlear
implants are responsible for:
 Maintaining and troubleshooting the equipment
 Providing transportation to 1 or more therapies
 Providing academic support beyond the level typical of hearing children
 Facilitating opportunities for social skill development
 Advocating for education and rehabilitation services
 Educating school personnel about cochlear implants and the impact of hearing
loss on development
Parents need to understand the importance of their continued involvement in the
rehabilitation process and receive support from the rehabilitation team to follow
through with the recommendations. The following questions should be addressed
148 Soman et al

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.

COMMON SCENARIOS AND REHABILITATION PLANS

The following scenarios illustrate case examples commonly experienced by implant

teams. They show the variability in the rehabilitative process and conclude with
possible recommendations. For each of these examples, it is assumed that the child
is receiving audiological and otologic management, and that teachers and profes-
sionals are included in rehabilitation planning.

Case Example 1: Isabella

Case history
Isabella is a 14-month-old girl who failed her newborn hearing screening. She was
diagnosed with a congenital severe-to-profound bilateral sensory hearing loss by 3
months of age and received hearing aids by 4 months. Isabella’s family was referred
to the local early intervention agency by her pediatrician and was found eligible for
speech and language services provided through part C funding. The parents chose
spoken language as the primary mode of communication for Isabella and started
working with an early interventionist. Isabella met the candidacy requirements for
a cochlear implant and is scheduled for surgery next month. Speech and language
evaluations indicate that Isabella functions like a 6- month-old to 9-month-old in the
areas of speech, receptive language, and expressive language, and a 9-month-old
to 12-month-old in the areas of play skills and social-emotional development. Her
parents have indicated that Isabella will attend a full-time community childcare
program after the cochlear implant surgery.

Rehabilitation recommendations

 Early intervention services

 Work with an early interventionist or speech-language pathologist who is
trained to develop listening and spoken language with infants and young chil-
dren who have a hearing loss.
 Review the current IFSP and include objectives that facilitate development of
age-appropriate auditory, language, speech, and cognitive skills.
 Consider a community childcare program that follows a developmental curric-
ulum and has peers who can serve as language models.
 School-based rehabilitation
 Request a developmental evaluation through the early intervention agency
when Isabella is 30 months old.
 Arrange an IEP meeting with the local school system to assess eligibility for
special education services. If Isabella shows any delays and qualifies for
services, consider the following recommendations:
- Receive services from a teacher of the deaf and speech-language patholo-

gist to develop age-appropriate listening, language, and academic skills.

150 Soman et al

- Evaluate acoustics of the classroom environment and make modifications to

maximize auditory access.
- Assess the need for assistive listening devices (eg, frequency modulated
systems and soundfield systems).
The rehabilitation team should review these recommendations at least annually.
Updates should be made based on Isabella’s progress and the family’s current desired
outcomes.

Case Example 2: Marcus

Case history
Marcus is a 6-year-old boy who passed the newborn hearing screening and was not
diagnosed until age 2 years with a severe-to-profound bilateral sensory hearing
loss. He received hearing aids within 1 month following the diagnosis and qualified
for early intervention services through part C funding. Marcus received early interven-
tion from a teacher of the deaf. Marcus’s parents want him to learn ASL and spoken
English.
Currently Marcus is enrolled at his local public school in a self-contained classroom
for students who are deaf and hard of hearing. The teacher of the deaf provides
instruction in both sign and spoken language. Marcus is in this classroom for most
of the school day but attends physical education, art, and lunch with his hearing peers.
Speech and language evaluations and academic progress reports indicate that Mar-
cus has age-appropriate sign language skills. His listening and spoken language skills
are 2 standard deviations below average.
Marcus’s parents want him to receive a cochlear implant so he can improve listening
and spoken language skills and interact independently with people who do not know
sign language. Marcus has met the cochlear implant candidacy requirements and
surgery is scheduled for next month.

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.

- Update placement and services to maximize meaningful interaction with

hearing peers.
- Continue services with a teacher of the deaf to develop age-appropriate

language and academic skills.

- Increase services with the speech-language pathologist to develop age-

appropriate listening and language skills.

Children with Multiple Disabilities

Approximately 40% of children with hearing loss have a sensory, cognitive, or neuro-
logic disability in addition to hearing loss.12 Today, the presence of a concomitant
disability rarely precludes a child from receiving a cochlear implant. Studies indicate
that children who have additional disabilities show progress in speech perception
and language skills after implantation, but the rate of progress is slower than typically
 Rehabilitation for Children with Cochlear Implants 151

developing children with hearing loss.20,27,28 The presence of multiple disabilities

requires the rehabilitation team to address these additional needs:
 Inform parents about the potential impact of the additional disability on
outcomes.
 Include professionals who are experts in the other disability/disabilities as part of
the child’s rehabilitation team.
 Establish realistic but high expectations for the child, noting that these might be
different than those for children without additional disabilities who have similar
audiological profiles.

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.

Children from Bilingual Families

The number of bilingual families in the United States is steadily increasing. According
to the 2005 to 2009 American Community Survey, nearly 20% of the population
speaks more than 1 language at home.29 Similarly, 20% of children with hearing
loss live in a home where English is not the primary language.12 Two issues commonly
seen with bilingual families are (1) parents and caregivers have limited English profi-
ciency, and (2) parents are bilingual and want the child to be bilingual as well. There
is a dearth of research related to effective practices for intervention for families who
do not speak English. Furthermore, there are a limited number of professionals who
are bilingual and can provide services in the home language.30
Retrospective studies of children who have hearing loss and are reported to be bilin-
gual suggest that it is possible for children who receive a cochlear implant at a young
age and participate in auditory therapy to develop spoken language skills in 2
languages.31,32 Some characteristics that were observed in children who were
successful in developing 2 spoken languages were early age of implantation, consis-
tent use of cochlear implant following implantation, focused therapy to develop
listening and spoken language skills, parents fluent in the second language, consistent
second language exposure at home, no additional disabilities, and better-than-
average speech perception skills.32 However, rehabilitation strategies that facilitate
development of 2 spoken languages for children with cochlear implants are not well
established and need further investigation.

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.

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