A U D I O L O G Y T O D A Y

O C T O B E R 2 0 0 3

COORDINATIONOFCOCHLEARIMPLANTSERVICES

Focus Topic

Caring for America’s Hearing

AMERICAN ACADEMY OF AUDIOLOGY • 11730 PLAZA AMERICA DRIVE • SUITE 300 • RESTON, VA 20190

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Many years ago, before I worked in acochlear implant center, I referredpatients to other centers when it was

time to consider a cochlear implant (CI). Onone such occasion, a mother called me withsome questions and concerns after visitingthe center. I called the center to try and dis-cuss the mom’s concerns. The audiologist atthe center told me, in no uncertain terms,that the child was now their patient andthat I no longer had anything to discusswith them. She then hung up.

I learned a great deal from that interaction.Because I was not involved with patientsafter they received their implants, I reallydid not know what kind of benefit to expect.If I were not going to have contact withpatients who were referred for a cochlearimplant, it was clear that I would never fullyunderstand how well a cochlear implantpatient could do. The experience confirmedfor me what we all know at some level - thatwe can accomplish more for our patients ifwe work together.

The CI team is, in fact, a large one. First onthe team is the patient who is team captain,and the patient’s family. If the patient is achild, then the parents are the captains of theteam. (While we frequently consider our-selves to be the captains, it is worthwhile toremember that the patient is in charge. Thepatient or the patient’s family decides whatservices they want and where they willreceive them. We can make recommenda-tions, but we are not the final arbiters ofwhat is done.)

Team members from the cochlear implantcenter will include an audiologist, a sur-geon, a social worker, an auditory therapist,and possibly a psychologist and an educa-

tor. Also on the team is school staff person-nel such as the classroom teachers, assistantteachers, speech-language pathologist, audi-tory therapist, teacher of the deaf, and/ortutors as well as school principal and othersupervisors. Some children will have audi-tory therapy or speech-language servicesfrom clinicians outside of school and whoincluded. If the child has services not direct-ly related to hearing (occupational andphysical therapy), these service providersare tangential team members. Other teammembers may include primary care physi-cians, other audiologists, otolaryngologists,and other medical staff. Adults may includework force personnel on the team if theyneed assistance with employment issues.

We all need to recognize that the CI team is alarge one. While it is difficult to communicatewith people who do not work at our facility,we have learned that we if we can developgood communication systems and learn towork as a team, the patient and patient’sfamily benefit – and we benefit too by provid-ing the best possible hearing health care.

This special section of Audiology Today hasarticles about coordinating efforts forcochlear implant patients written by teammembers from a number of different worksettings. They include an audiologist,surgeon and educator from a CI center, aschool audiologist, an auditory therapist inprivate practice, a speech-language patholo-gist specializing in adult aural rehabilita-tion, the parent of a young CI user, an adultCI user, and an audiologist who works for aCI manufacturer. It should be good readingfor audiologists in all work settings sincethe coordination of services issues is notlimited to CI patients alone.

editor’s introduction

FOCUS TOPIC:

Coordination of Cochlear Implant Services

Table of Contents

Introduction FT 1Jane Madell

The Role of the FT 2CI Center AudiologistJane Madell

The Surgeon FT 3Ronald Hoffman

The School FT 3AudiologistRebecca Kooper

The Educator FT 5Susan Cheffo Seth

The Auditory Therapist FT 7Lois Kamm Heymann

Adult Aural FT 8RehabilitationPatricia Rothschild

The Parents View FT 10Cecile Major Seth

The Adult in the FT 11WorkforceDonna Sorkin

The Manufacturer’s FT 13ViewKristine Rafter

Commentary: FT 15Court Ordered CI MappingCheryl DeConde Johnson

Response to FT 19JohnsonK. Todd Houston

Jane R. Madell, PhDFocus Topic Editor

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Jane R. Madell, PhD

Audiologists who have been responsi-ble for hearing aid management of apatient may feel cut out of the loop

when a patient is ready to consider acochlear implant. The audiologist mayhave been managing the patient for anumber of years dealing with hearingaids, and providing support as thepatient’s hearing loss becomes increas-ingly severe. It is likely that when thehearing loss progresses, both the patientand the audiologist will be reluctant topart and to have the patient referred toanother audiologist for care. As a result,many patients do not get referred forcochlear implant consultation as early asthey might. In addition, since the patientdoes not usually return to the audiolo-gist following the implantation, the clini-cal audiologist frequently does not havea good sense of how well people do withtheir CI. This results in the audiologistmaking fewer implant referrals. If audi-ologists in general practice were moreinvolved with CI patients and couldobserve first-hand the benefit receivedfrom implants, they might refer patientsearlier. This alone, is a good reason toimprove communication between thegeneral audiologist and the CI center.

Once patients are referred for a CI con-sultation, the CI center will evaluate thepatient to determine appropriate candi-dacy. A significant part of the evaluationis based on the determination of thepatient’s current benefits with amplifica-tion. It is sometimes determined that thehearing aid the patient is wearing is notadequate and that, with better amplifica-tion, the patient is capable of function-ing well enough to not consider a CI atthis time. However, if it turns out that CIis appropriate, the patient will not bereturning to the general audiologist.

The patient might be better served ifcontact with the clinical audiologistcould be continued. This could be donein a number of ways. When a patientcomes for a cochlear implant evaluation,the implant center needs audiologicaland amplification information that couldbe provided by the audiologist who hasbeen following the patient. The CI centeraudiologist should communicate with

the clinical audiologist in the same wayin which we communicate with otherreferral sources. With patient permis-sion, the general audiologist shouldreceive reports describing test results,recommendations, and progress reportswith the implant. This is a courtesy tothe referring clinical audiologist and willlikely encourage future referrals.

After successful cochlear implantation,patients may consider using a hearingaid on the unimplanted ear.Audiologists at both centers should con-tinue to work together by having theclinical audiologist continue to managethe hearing aid on the patient’s unim-planted ear. This is a reasonable consid-eration since the clinical audiologistmay well know more about currenthearing aids than the audiologist in theimplant center.

Coordination between CI Center andOtolaryngologists outside the CenterOtolaryngologists who are not involvedin cochlear implantation may have simi-lar reservations about referring patients.CI centers which make an effort to com-municate well with referring otolaryn-gologists are likely to increase referralsand reduce concern about loss ofpatients. Otolaryngologists involved incochlear implantation are usually alsoinvolved in other aspects of otolaryngol-ogy practice and can take over generallyotologic management of a cochlearimplant patient. However, returning thepatient to the referring otolaryngologistfor non-cochlear implant issues maymake good sense in building relation-ships for future referrals.

Coordination between CI CenterAudiologist and the SchoolIt is critical that there be good commu-nication between the school and the CIcenter. This may happen by having CIteam members visit the school or hav-ing school staff visit the CI center. Theschool staff needs to know how to trou-bleshoot the CI, how to select and useFM systems, how to know when the CIneeds repair, adjustment or additionaltuning, and how to maximize function-ing in the classroom. The audiologists

at the CI center and at the school candevelop good communication patterns.If there is an educator on the implantcenter team, the educator may be theperson who can facilitate communica-tion between the school and the center.The educator will understand best howto improve functioning in the class-room. Each team will need to developit’s own methods of maximizing func-tioning, but the overall program willwork best if everyone understands thatthe team consists of many people fromdifferent work settings.

Coordination between CI CenterAudiologist and Speech Pathologistor Auditory TherapistMany children with cochlear implantswill be receiving services from auditoryoral or auditory-verbal therapists in oroutside of the school system. These clini-cians can provide a great deal of infor-mation that will be helpful in improvingcochlear implant MAPping. The CIcenter audiologist will need to providethe auditory therapist with the sameinformation that the school needs includ-ing how to troubleshoot the implant,how to select and use FM’s, and how toknow when a new MAP is needed. Theimplant center will benefit from informa-tion that the therapist can provideincluding situations in which the child ishearing well, not hearing well, and spe-cific phonemes that the child cannot per-ceive. This information can be used toassist the CI center audiologists in modi-fying cochlear implant maps to provideimproved benefit. The therapist canassist the CI center in helping to commu-nicate with the family and helping tomonitor use of the implant at home.

Coordination between CI Center andthe WorkplaceWhile it is clear that there needs to becommunication between the CI centerand a child’s school program, there isless agreement on what is needed foradults with CIs. Some adults will beable to advocate for themselves in theworkplace, but others will need assis-tance. It is important for the CI centerteam to discuss workplace issues withadult patients and ask if assistance is

Coordination Between Audiologists at the Cochlear Implant Center and the Hearing Aid Center

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needed. When a CI patient goes to anemployer and asks for a phone device,a desk away from a noisy area, or assis-tance hearing in groups, the employermay view the person as “difficult.” CIcenter staff who meet with the work-place staff or supervisors will be in abetter position to explain what the per-son can and cannot hear with the CI,

and what can be done to improve com-munication. As is frequently the case,an outsider can often make a point thatcannot be made by the patient directly.

Improved communication among andbetween professionals can only benefitpatients. It can also make work morepleasant and open up more doors.

Jane Madell is the Director of the Hearing and Learning Center and Co-Director of the Cochlear Implant Center at Beth Israel Medical Center, NY and Professor of Clinical Otolaryngology at the Albert Einstein College of Medicine.

Cochlear Implantation:The Expanded Role of the SurgeonRonald A. Hoffman, MD

The role of the surgeon has evolvedand changed with the increasedaccess to cochlear implantation as a

preferred form of auditory habilitation.Cochlear implantation, in the past, hasbeen part of an inverted pyramid withthe entire implant program sitting onthe shoulders of “the surgeon.” This istypical of new medical interventionsthat involve a complex surgery. It isanalogous to cardiac surgery in the late1960’s - 70’s. If you needed heart sur-gery and you could afford it, you wentto Texas and saw Michael DeBakey orDenton Cooley. Now, you see your localinternist, go to your local cardiologistand have your heart surgery at yourlocal hospital.

The same is true of cochlear implanta-tion. In the early years it was a searchfor the “big name doctor.” Today,cochlear implantation is a routine surgi-cal procedure with relatively low risk.The inverted pyramid has been flippedand the foundation is no longer the sur-geon but rather the Hearing, Speechand Language Center. Children andtheir families come to the Center fordiagnosis of hearing loss, amplification,

educational consultation, speech andlanguage therapy and, at the end of theday, cochlear implantation if necessary.

Since surgeons have “disproportionate”power and influence in the hospital envi-ronment it becomes the surgeon’s respon-sibility to assure that the “foundation” ofthe pyramid is robust. The Hearing andSpeech Center must offer all necessaryservices to both adults and children.Excellence in care of children, in particu-lar, is maximized by an active outreachprogram. Such an initiative involves edu-cating all professionals and paraprofes-sionals who deal with the hearingimpaired child. This includes teachers,speech and language professionals,audiologists, physicians and, importantly,parents and family members.

The Cochlear Implant Center shouldoffer in-house conferences for teachers,speech and language professionals,audiologists, physicians and parents andfamily members. We survey school pro-grams in our geographic area andarrange for regional meetings as well.Our presentations involve all membersof the patient care team including a

presentation by one of our staff physi-cians, if possible. The role of the physi-cian is important for two reasons. First,the physician has information to impartabout medical candidacy criteria for sur-gery, what is involved with the surgery,and the risks and expectations. Secondly,the surgeon has the opportunity toemphasize the importance of the keyissues that will be covered by the audi-ologist, speech pathologist and educatorin their talks. The presentation of a uni-fied and consistent philosophy andapproach to management reinforceseach of the elements.

Cochlear implantation has evolved as aprototypical team approach to health care.The surgeon is one key player on thatteam and it is his/her responsibility to beinvolved in both in house managementand outreach programs. This reinforcescontinuity of care and dissemination ofthe best and most useful knowledge.

Ronald Hoffman is Director of Otology andCo-Director of the Cochlear Implant Centerat Beth Israel Medical Center, New York.

Rebecca Kooper, AuD

Educational audiologists and CI audi-ologists need to establish a goodworking relationship. These people

will be sharing many clients over theyears and a positive outlook regardingthe role of each in the CI process isessential. Both parties have unique per-

spectives that can contribute to theassessment of the child’s cochlearimplant candidacy and ultimate suc-cess with an implant.

The educational audiologist often seesthe child when the child enters an early

intervention program. The early inter-vention program provides language,speech and auditory therapy for thechild as well as support for the parents.The educational audiologist’s role dur-ing this time is varied. Skills and tasksneeded at this time include:

Coordination Between the School Audiologist and the Cochlear Implant Audiologist

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• Staying up-to-date on the constantlychanging criteria for cochlearimplant candidacy.

• Providing parents of children whomeet the audiological criteria for can-didacy, (information about cochlearimplants). Although other factors maypreclude a child from becoming acochlear implant candidate, it is therole of the cochlear implant center tomake that final determination.

• Identify older students who may nowbe a candidate for a cochlear implant.Since criteria has expanded over thelast 10 years, older students who werenot considered for cochlear implantyears ago, may now qualify for acochlear implant. These children mayinclude those with other handicappingconditions and those students who arenot in oral/auditory only programs.

• Ensuring (with the clinical audiologist)the use of appropriate amplification inorder to provide the maximum audi-bility of speech sounds to the child.

• Referring a child to a cochlearimplant center when appropriate.

It is essential that accurate resultsregarding the nature and degree ofhearing loss be determined for thepediatric CI candidate. Communicationbetween audiologists and comparisonof audiological test results will result ina more accurate assessment. The educa-tional audiologist may have the oppor-tunity to see the child more often andin a familiar setting which can improvetest reliability. An open communicationabout these findings is essential, espe-cially when there is a disagreementabout the test results. Neither partyshould be defensive when test resultsare not in agreement. It is important toremember that the child should be thecenter of the discussion, not the audiol-ogist’s testing abilities. Excellent audiol-ogists can get different results on veryyoung children. Working together toresolve the differences will only ensureoptimum test results.

Children who have good pre-implantauditory skills will usually adapt to theCI with ease. The educational audiolo-gist will work with an early interven-tion expert, the teaching staff, to makesure auditory skills are progressingcommensurate to the degree of hearingloss. The educational audiologist canthen report these auditory levels andresponses to the cochlear implant center

to assist them in deciding candidacy. Atthe same time, the cochlear implantcenter needs to keep the educationalstaff apprised of the progress of the CIevaluation. The educational audiologistcan then support the parents throughthis process. Parents are often over-whelmed during this process.Questions often arise immediately afterleaving the cochlear implant center ordays after an appointment at thecochlear implant center. The education-al audiologist can serve as a resourcefor the parents. Parental anxiety can bealleviated when they hear the sameinformation from both the CI team andthe educational audiologist and staff atthe educational program. This coordi-nation is essential since parents areoften apprehensive at this point.

The cochlear implant team’s role is tomake the final determination regardingcochlear implant eligibility. Once thisdecision has been made, preparing thechild and the parent for surgical andpost surgical procedures is done by theaudiologist at the cochlear implant cen-ter. However, for the older child, havingschool staff review stories regarding hos-pitals and surgical procedures may behelpful. The staff that works with thechild in school must be prepared toanswer questions that the child may askregarding the surgery and the cochlearimplant. The educational audiologistneeds to let the cochlear implant teamknow about any unusual reactions thatthe child may be showing in school.Either the school or the cochlear implantteam may want to provide extra coun-seling for the child who is demonstrat-ing unusual apprehension regarding thecochlear implant.

On the day of surgery, the audiologist atthe CI center works with the surgeon toensure that the implant is working andthat the auditory nerve is responsive tostimulation. After CI surgery, the educa-tional and CI audiologists should worktogether to arrange for some members ofthe educational staff to attend the initialmapping. The initial CI mapping is doneby the CI center staff who will thenreview the speech processor with theparents and child. An initial schedule forthe use of different maps will be devel-oped by the CI audiologist to be sharedwith the families and the educationalaudiologist. The educational audiologistshould share this information with the

school staff who will be checking speechprocessor settings at the beginning of thetherapy/school day.

After CI surgery, both the cochlearimplant and educational audiologistswill become members of an educationalteam that will make recommendationsregarding the child’s placement, relatedservices and need for FM technology inthe classroom. Both audiologists shouldmeet prior to a team meeting to developa unified recommendation for the child.

Once a decision regarding educationplacement and services has been deter-mined, the audiologists need to planworkshops collaboratively. Periodicworkshops are essential to provideinformation and support with person-nel who are providing dailytherapy/education to the child with acochlear implant. School personneltypically include a speech therapist,teacher of the deaf, teacher of a regularmainstream class, teacher specialistswho work with the child includinggym, art, music, library and computerteachers. While it is often difficult forthe audiologist from the cochlearimplant center to go to schools formonthly workshop presentations, thetopics to be covered should be a resultof input from both audiologists. Whilethe educational audiologist usuallypresents these workshops to the staffwith whom she works, it is recom-mended that the audiologist from thecochlear implant center come out tothe school at least annually to supportthe educational audiologist and to pro-vide their unique perspective to staff.Workshops should include but not belimited to the following topics:•How the cochlear implant works and

the different progress that can beexpected from children dependingon the age of implantation, length oftime that child was deaf, level ofpre-implant auditory, speech andlanguage skills and other factorsunique to a specific child includingcognitive levels, and existence ofother handicapping conditions.

• How the speech processor worksand how to do a daily check of set-tings. What “mapping” the speechprocessor means and why childrenwill often have a schedule of mapchanges, especially during themonths immediately followingimplantation. School personnel need

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to work with parents to note obser-vations of the child’s auditoryresponses to the different maps.

• Instruction on how to identify aneed for re-mapping so that thera-pist and/or teacher can be on thealert for the need for a new map.

• Teachers working in schools for thedeaf and hard of hearing often havechildren with different types ofspeech processors in one class.Providing written information oneach processor is essential.

• How to do basic troubleshooting ofthe processor is critical. Batterieswill often go dead in the middle ofthe school day. Teachers need to feelcomfortable changing batteries in thespeech processor.

• Providing information on auditoryskill development and expectation is essential. Children with a cochlearimplant should make consistent andsteady progress in their developmentof auditory skills. This progress canonly occur if the personnel workingwith the child understand the needto continually expand auditory skillsand to incorporate those skills in theclassroom and therapy session. Lackof auditory skill expectation will sig-nificantly hamper a child’s progress.The therapist and teacher must

understand how important their roleis in the child’s successful use ofhis/her cochlear implant. Specialtechniques for auditory expectationof children who use sign languageshould be reviewed, as auditory onlyopportunities need to be providedduring the day for these children.

• Providing information on electro-static discharge management willreduce the number of problems withimplant functioning.

• Providing information on the needand proper use of FM system in theclassroom is also critical. While acochlear implant will provide muchmore benefit than is available for ahearing aid, it is still necessary to usean FM system if the child is going tomaximize listening in the classroom.

Other ConsiderationsThe educational audiologist is usuallythe person who makes recommenda-tions regarding the use of an FM sys-tem in the classroom. The teaching staffneeds to learn how to perform daily lis-tening checks of the FM system andbasic troubleshooting, when needed.

The educational audiologist often seesthe child on a regular basis whenhe/she comes in for therapy/school.

The audiologist can observe the childin a therapy session or classroom andcan obtain information from the thera-pists regarding the child’s auditory,speech and language development.This information can be shared withthe cochlear implant team so that theycan make any necessary adjustmentsto the speech processor to ensure con-tinued auditory skill progress. Theeducational audiologist and CI audiol-ogist will work out procedures to fol-low when the speech processor is inneed of repair. The school may chooseto keep certain spare parts on handsuch as cables, batteries and transmit-ting coils for emergency repair.

Cochlear implants have brought audi-tory access to speech and language tomany children who would have beenprecluded from this experience withhearing aids alone. The educationalaudiologist and the CI audiologistshould consider themselves part of thesame team. Together, they can enjoythe experience of providing newopportunities to deaf children who usecochlear implants.

Rebecca Kooper is an Educational Audiologist at Nassau BOCES in New York.

Working Together:The Educational Consultant and the SchoolSusan Cheffo, MS

The Role of the CI Center Educator

The educational experiences ofcochlear implant children can bestbe managed if there is an educator

from the CI clinic working togetherwith the school. This develops a part-nership where the educator and schoolshare information about the child andare working toward a similar goal ofmaximizing the youngster’s educa-tional experience. Although childrenwho receive cochlear implants showsignificant improvement in speech andlanguage, their ability to hear in noisemay be problematic. Hearing in theclassroom and within the school envi-ronment can impact learning andsocialization. The educator needs toprovide information about cochlearimplants, hearing loss, acoustics, etc.

while the school needs to be open tomaking adjustments for the child andcommunicating with the CI centerwhen problems develop. Providinginformation about student perform-ance is important for the educatorfrom the CI center who needs to betuned in to the needs of the schoolwhile keeping in mind the child’sfunctioning ability. With a positiveconnection, a true partnership can beformed and the child’s educationalexperience will flourish.

The educator from the CI center is theliaison between the school, family, andcochlear implant center and, therefore,needs to develop the skills to maintaina good relationship. Since educatorsfrom cochlear implant centers stronglybelieve in maximizing each child’sauditory, speech and language poten-

tial, the emphasis toward an audito-ry/oral program is preferred wheneverpossible. The educator works with stafftoward that direction by helping tomodify teaching techniques and work-ing with speech therapists to use effec-tive remedial approaches. This can be asensitive issue for some schools thatfeel confident in their educational pro-gram and are not open to change.

Maximizing CommunicationEducators need to develop an ongoingrelationship with various schools orprograms for children of all ages. Somemeans of developing these relation-ships are the following:• Find a “contact person” within the

school via parent or district personwho should be called after implantcandidacy is established. Begin on apositive note with this person, offer-

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ing information to staff workingwith the child. Be friendly and askhow the school may need the educa-tor’s help.

• Set up a workshop or small meetingwith school personnel who workwith the child. Include all membersof the child’s team such as speechpathologist, audiologist, teacheraide, interpreter, etc.

• Be well prepared for this workshop.Although the educator cannot knoweverything about every implant andteaching method, s/he should gatherknowledge about the child’s cochlearimplant, classroom acoustics, modi-fying teaching techniques, providingauditory learning techniques, etc.Having printed handouts of thisinformation is helpful for personnelto read after the workshop.

• Meet school administrators. It isimportant to develop positive publicrelations skills in meeting adminis-trators, secretaries, and other schoolstaff. Once administrators under-stand the importance of FM equip-ment, a positive acoustical environ-ment, teaching modifications, teamcollaboration, and parent participa-tion, there is greater assurance of asuccessful educational experience.

• Use diplomacy. Make sure the educa-tor acknowledges the staff who workwith the child and their knowledge ofthe child’s academic performance.Listen effectively to school personneland acknowledge the positive learn-ing experiences they have providedfor the implanted child.

• Be a resource to school personnel.Provide additional information to staffwhen requested, such as where to findpicture cards for the Ling 6-SoundTest, or where to buy acoustic absorp-tion tiles. Always get back to theschool once information is obtained.

It is important to observe the child dur-ing individual sessions such as duringan itinerant session or speech.Observing a child during a privatespeech session such as during anAuditory-Verbal therapy session willgive the educator information abouthow this child functions optimally. Theeducator will then understand better

the need for school personnel toincrease their expectations for the child.

How does the educator address the lackof expectation or insufficient teachingmethods to school personnel withoutdamaging their relationship? This iswhere the art of diplomacy and usinggood, common sense is necessary. Towrite or not to write observations/sug-gestions must be constantly addressedby the educator. If the educatorobserves areas that need improvement,should it be put in writing for follow up,verbally addressed with staff, both ofthose, or put under the table for a latertime. The educator needs to have agood understanding of the school andits personnel. If s/he is asked to writesuggestions by an administrator orsupervisor, then writing would be valu-able. Make sure suggestions and/orobservations are written in the third per-son and cite examples when available.

It is a good idea to communicate withadministration regarding suggestionsto help the child in class. After men-tioning these suggestions to adminis-tration, ask if s/he wants the educatorto talk to the teacher about these sug-gestions, whether they should be putin writing, or whether administrationwants to handle it.

Educators should use caution whenobserving in the mainstream setting.There may be itinerant teachers work-ing with the child who work other cen-ters. Writing observations/suggestionsmay conflict with recommendationsprovided by others. An example of thisis involves an educator who observed athird grade student in his mainstreamedschool. During that observation it wasnoted that the desktop speaker was notgiving the child full benefit because itwas placed on a hook behind the childand not on the child’s desk. The educa-tor placed the speaker in a more benefi-cial location by relying on studentresponse, and proceeded to write this tothe school as a “suggestion.”The pro-gram that supported itinerant serviceprovider read this and immediatelycalled the clinic to express concern.“How could this be put in writingbefore discussing it with us?”Even withmany apologies, it took a long time

before that relationship was repaired.

What Does the Clinic Educator Needfrom the SchoolIn turn, what does the educator needfrom the schools? The school can dothe following:

• Inform the clinic as to any changes inlistening ability, change in voice qual-ity, or speech production. These mayindicate the need for a new MAP. Theeducator can be the liaison.

• Communicate with the educatorregarding any changes in academicperformance. This may be an indi-cation of the need to modify teach-ing techniques, equipment, or ofdeeper issues.

• When educators go to the school,greet them positively. Sometimes along drive or train ride is necessaryand a smile and open door would begreatly appreciated.

• Follow the schedule set up for thevisit. Any changes should be dis-cussed with the educator prior toarriving.

• Notify the clinic/educator if a childis absent. That way a wasted trip canbe eliminated.

• Share information graciously, with-out being defensive. Having theeducator and schools collaboratewill only benefit the child.

• Make parents part of the team. Theschool and educator need to planhow to express concerns to parents.Progress and school successesshould also be shared.

With the educator providing ongoingsupport to the schools, and the schoolssharing information with the clinic, areciprocal relationship can develop thatwill benefit the child with a cochlearimplant. Working together is the key toa positive educational experience for alldeaf and hard of hearing children.

Susan Cheffo is a Teacher of the Deaf andHard of Hearing. She is the Coordinator ofEducational Services in the CochlearImplant Center, Beth Israel Medical Center,NY and a bilateral cochlear implant user.

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Lois K. Heymann, MA

The team is everything

Aspirit of collaboration and mutualrespect among professionals, par-ents and school staff is the key to

success in the use of cochlear implantsand related therapy for hard-of-hearingand deaf children. As an independentspeech-language pathologist workingwith hard-of-hearing and deaf children,it is crucial to establish a team approachfrom the outset. This includes strongprofessional alliances which provideinput, feedback, perspective and eveninspiration. A close partnership with thechild’s parents or caregivers which iscentral to an effective auditory-oraltherapy program.

By having a parent in the therapy room,“teaming” becomes natural and vital tothe process. Working closely with thechild’s school, other therapists and, ofcourse, the audiologist, leads to better andmore informed therapy. When a childreceives a cochlear implant, that child andhis or her family also gain an implantteam - another key partnership that mustwork effectively to achieve results.

Communication, respect, professionalismThe three principles that guide the bestteams are communication, respect andprofessionalism.

When a child is referred for auditory-oral(auditory-verbal) therapy -whether thechild is newly diagnosed, pre-implant orpost-implant – the initial team contact ismost often the audiologist. Cultivating agood relationship with the audiologist,based on communication, respect andprofessionalism, is a critical foundationfor effective therapy overall.

In most instances before implantation,auditory-oral therapy with hearing aidsor FM systems has been initiated, andimportant data has been gathered. Is thechild alerting to sounds? Is the childattending to and responding to sounds?Is the child discriminating sounds? Is thechild vocalizing? What is the quality andquantity of the vocalizations? What arethe parents’ questions and concerns?

This information is extremely importantto the implant team both pre- and post-implant. Other members of the team con-tinue to conduct assessments, the resultsof which need to be considered and incor-porated into the therapy program. Thetherapist needs to know the results of pre-liminary tests and assessments done bythe audiologist, speech-language patholo-gist (often done by another therapist forbaseline information), social worker andsurgeon, the dates of implantation, activa-tion and initial MAPpings. The therapistneeds to know:• What CI processing strategy is being

used. • What MAPing changes have been

made from one program to the next inthreshold levels and in comfort levels.

• How the child should move throughthe programs, (i.e.: stay in each pro-gram until changes in performanceindicate the need to move on, or coor-dinate each program change accordingto the time of the next MAPing.).

• If there is a high- or low-frequencyfocus to the MAP program.

The best way for this information to reachme is simply putting it on a cover page tothe MAPing data, (See Figure 1) which theparent can bring to the therapy session. Ican then keep a copy in my file and referto it as I conduct listening therapy andobserve the child’s responses.

At the same time, my responsibility tothe team is to clearly convey observa-tions and data about how the child isresponding to the programs, and if thereare difficulties or problems. Typically Icommunicate this information to theteam via the audiologist.

In addition, with the information pro-vided by this form, the therapist canhelp parents understand the MAPingchanges and educate them about theeffects these changes have on the child’slistening and learning.

Including school staff Communicating with the team’s educa-tional consultant also needs to be initiat-

ed and maintained. Having the consult-ant observe therapy helps to strengthenawareness of the child’s progress and anydifficulties the child may have in acquir-ing listening, language and speech skills,which have a direct impact on education.

The consultant’s input is also invaluableat IEP meetings. In conjunction with theauditory therapist, the consultant canimprove and increase in-service educa-tion to the school staff, which will help tosuccessfully mainstream a child with acochlear implant. Most public schoolteachers have little or no experience edu-cating a hard-of-hearing child, so thepresence of CI team members at thesemeetings will help the school staffunderstand this new situation and devel-op appropriate support services andexpectations in the classroom.

Educating the professional communityFinally, the CI team can help profession-als outside the team through continuingeducation. In this instance, the implantteam can educate the professional com-munity about working effectively withthe cochlear implant, updates on changesin implant criteria and capabilities, andtherapeutic and educational strategies.Workshops for speech-language patholo-gists, teachers of the deaf, mainstreamschool staff, parents, and audiologists canbe necessary to keep everyone informedand current.

Lois Heymann is a speech-language patholo-gist and an auditory-oral therapist workingin private practice in Nyack, New York. Sheis the consultant in the auditory-oral pro-gram at the New York School for the Deaf.

Cochlear Implant Services and the Speech-Language Pathologist

Figure 1: Sample MAPping report form(Pediatric Cochlear Implant Report, The Cochlear Implant Center, Beth Israel Medical Center, NY )

NAME: Type of Implant:

SPEAK:

PROGRAM DIRECTIONS: Prog 1

Prog 2

Prog 3

Prog 4

Optimal setting Volume: Sensitivity

Next appointment date:

Comments

Audiologist:

FT 8

Aural Rehabilitation for Adults with a Cochlear ImplantPatricia Rothschild, MA

The onset of severe or profound hear-ing loss for an adult who has hadnormal hearing or who had made the

adjustment to milder levels of hearingloss, is devastating. Although hearingaids do not restore normal hearing ornormal communicative functioning, theyoften do make it possible for individualsto maintain employment, family andsocial contacts and community involve-ment. These abilities slip away as theseverity of hearing loss increases and thebenefit from hearing aids decreases. It isnot unusual for such a person toapproach cochlear implant candidacywith anxiety and trepidation. Theprocess often continues to be fraughtwith these emotions as one struggles tokeep hopes high but expectations incheck; to worry about impending disap-pointment in store for well-meaning andcaring family and friends who some-times seem to believe that a cochlearimplant is the “miracle cure” for deaf-ness and all its related problems. Indeedit is not. Although implants provide sig-nificant benefit to many people, they arenot an instantaneous or a miracle cure. It is no wonder that, after gettingthrough the surgery and any post-surgi-cal difficulties that may occur, by thegreatly anticipated day of initial stimula-tion, the patient is under great stress. Nomatter how prepared a person is for theday of initial stimulation, it is likely thatthe implant will not provide the benefithoped for on the first day. No matterwhat the experience on that day, it gener-ally fosters feelings of relief that at theleast, the device works, provides hopethat hearing will improve over time, andincreases motivation to do anything andeverything that is suggested by anyoneto achieve the best possible benefit fromthe cochlear implant.

While the level of technology of cochlearimplant devices and programmingstrategies has resulted in higher levels ofperformance after shorter periods oftime, especially for post-lingually deaf-ened adults, there continues to be a con-tinuum of performance for cochlearimplant users and no one in the field

appears to be comfortable making guar-antees or even predictions of success.

If indeed longer periods of experiencewith the use of the device will result inimproved hearing and understanding, itstands to reason that an aural rehabilita-tion program will do the following: • Qualify, quantify and describe areas of

auditory strength and difficulty • Offer specific guided practice in using

audition to recognize and compre-hend speech

• Develop a meta-linguistic understand-ing of perceptual errors and generalcommunication functioning

• Provide a forum for ongoing commu-nication and for support to the implantaudiologist regarding programming,and the possible need for special pro-grams to meet unique needs

• Explore benefits from the use of assis-tive devices

• Assure understanding and the properuse of cochlear implant accessories tofacilitate understanding and augmentperformance

• Respond to the motivation to workhard to attain the best possible bene-fit from the implant, and foster afeeling of positive empowerment inthe recipient.

Who is an appropriate candidate forAural Rehabilitation (AR) and when should it be initiated? Every adult who receives a cochlearimplant should be seen for an aural reha-bilitation evaluation. The reassurance andgratification of learning that progress hasbeen shown in developing auditory per-ception of speech and general communica-tion functioning goes a long way towardsatisfaction, empowerment and peace ofmind. An appointment for this evaluationshould be scheduled about four weeksafter the date of initial stimulation. Thissession should evaluate the patient’s func-tional communication in real world situa-tions. On the basis of the patient’s per-formance and if motivation exists, a com-pilation of goals and practice materialsincluding audio tapes and work on tele-

phone communication, at that individual’sspecifically appropriate level, can be pro-vided. A follow up assessment appoint-ment three months later can also be sched-uled. It is common for patients to reportinitially the euphoria of greatly improvedhearing, which is later clouded by the real-ity of those situations, speakers, or soundsthat emerge as persistently difficult. Thisfollow up appointment can address suchconcerns, as well as providing a plan forcontinued self-directed practice.

What should be included in the ARassessment? A general interview highlighting thepatient’s feeling regarding hearing wellbeing, environmental sounds and espe-cially speech that is now heard andunderstood and the reports from familyand friends, is the basis of the ARassessment. The patient should describethe communication demands he gener-ally experiences and how well thesedemands are being managed. A clearpicture should be obtained of how wellthe patient reports understandingspeech in a quiet one to one communi-cation setting, in group settings, innoise, at increased distances, for televi-sion, and when using a conventional orcellular telephone. It is important toprovide a receptive environment forsharing feelings of joy, satisfaction, dis-appointment, worry or concern relatedto the any aspect of the cochlearimplant. It is also essential that the pro-fessional have the knowledge to answerany question posed, or at least knowwhere to go for the answer, as well asthe ability to “troubleshoot” situations,speakers and words to determine whataspect of a reported problem to address.

Using both analytic and syntheticassessment, a communication profile isoutlined. A phoneme recognition pro-file is developed including vowel recog-nition, initial consonant and final conso-nant recognition using monosyllabicCNC words. Specific misperceptions arenoted and a feature analysis of percep-tual errors gives insight into the fre-

FT 9

quency or timing cues that are notbeing perceived correctly. It is possibleto determine whether patterns emerge,for example, misperception of the voic-ing feature at the end of words, percep-tual confusion among the voiceless plo-sives, or the phoneme /b/ substitutedfor /f/ in the initial position of words.These are all frequently seen perceptualerrors. Providing the patient with thisinformation can be extremely helpful inunderstanding difficulties he is experi-encing. Providing an explanation ofwhy this may be occurring as well asinstruction in how to utilize this knowl-edge to maximize understanding canbe a powerful rehabilitative tool. Thisinformation must also be communicat-ed to the audiologist who can thenwork with the patient to improvespeech processor programming.Comprehension of connected discourseis assessed to determine whether suchfactors as rate of speech, length and/orcomplexity of the message, presence ofcontextual cues influence the ability tocomprehend auditorily.

For pre-lingually deaf individuals whouse American Sign Language as their

primary mode of communication, thescenario is very different. These indi-viduals do not generally have an audi-tory representation of spoken language,the rules of grammar and phonology toact as a framework for what is heard. Itis necessary to think of the date of ini-tial stimulation as day one in terms of“listening age”, although it is not realis-tic to build the mosaic of spoken lan-guage one word at a time, as one woulddo for a young child An abbreviatedand more sophisticated way of doing somust be provided for these individuals,as they are at great risk for disappoint-ment and non-use of the device. Theprogram must be intensive and longterm, and goals and objectives must befocused and systematic. Auditory andspoken language experience and expec-tations must expand at the same timethat ASL continues to be the languageof life. Results can be excellent whenmotivation is supported and the teamworks closely together to address andresolve issues as they emerge.

In practice, numerous individuals intheir 70’s and 80’s have successfullyreceived a cochlear implant. While

results vary and can never be guaran-teed, virtually all recipients reportimprovement in their ability to hearenvironmental sounds and speech, andmost enjoy considerably improved abili-ty to understand speech in all situationswith far less effort and stress. Because ofthe factors noted above, aural rehabilita-tion for this group is particularly helpfuland often essential to attain satisfactorybenefit.

For all adults who receive a cochlearimplant, the partnership and supportafforded by an aural rehabilitation pro-gram is powerful in terms of instillingempowerment and motivation and fos-tering more rapid progress to higher lev-els of auditory performance.

Patricia K Rothschild is a speech-language pathologist in private practice in the New York-New Jersey area who provides auditory therapy to children and adults with hearing loss.

FT 10

Cecile Major Seth

As parents raising a hearingimpaired child, we have benefitedtremendously from the wisdom of

professionals and parents who madethis journey before us. In the threeshort years since our son, Ryan, wasimplanted, cochlear implant (hereafterCI) technology has evolved, implantages have decreased, and techniqueshave adapted, thus dramaticallyimproving prospects for today’s hear-ing impaired children to thrive in thehearing world. I would like to sharefactors we believe essential to our fami-ly’s success and the success of others.The first five factors, ranked in order ofimportance, apply to all hearing-impaired children, while the last fivefocus on CI candidates.

1. Act quickly Brain plasticity is ahuge factor in very young children. Asa result, early identification, amplifica-tion and parental education are invalu-able.1 Our biggest frustration was thatso many professionals and parentsseemed so content to “coast” and pro-crastinate decisions and actions. Adviseparents to cram as many sounds intoamplified ears in the first 18 months aspossible. A child must hear thousandsof repetitions before words start tohave meaning. Professionals and par-ents need to understand just howmuch of an impact they can make byacting quickly.

2. Amplify! Amplify! Amplify!Amplify children within hours or daysof identification, not weeks andmonths. Powerful hearing aids are dif-ficult to fit on rapidly growing toddlerswithout feedback. A body-worn FMsystem is quick and easy to fit, withbetter chance of reduced feedback athigh levels of amplification. Most par-ents would happily use the extra equip-ment if they understood how dramati-cally it increases their child’s chance tobe literate and go to college.

3. Educate parents aggressively. Donot assume all parents will be incapac-itated with grief. With time at such apremium, parents do not have the lux-ury of grieving anyway! Parents needto realize that they have to quicklyclimb a steep learning curve, and willneed to digest a large amount of infor-mation rapidly. Our own implant cen-ter pointed us to some great resourceson our first visit that focused ourhome therapy.2 ,3

4. Shoot for the moon – maybe youwill land on the top floor! CI chil-dren may catch up with their hearingpeers quickly if, and only if, weexpect them to. If, based on pastexperience with older technology, wehave unambitious expectations thenmediocre results are all we will get.

5. Focus on listening skills. We ini-tially tried Total Communication andthen an Auditory Oral approach. Weknew we had a winner when in hisfirst Auditory-Verbal session, Ryanspoke more than he had done in anentire week! After 22 months of see-ing and not hearing, he always priori-tized visual inputs over auditoryones. When forced to listen, and onlylisten, his speech improved immedi-ately and dramatically.

6. Choose a CI center carefully. Inaddition to a center with a multi-disci-plinary, team approach you shouldlook for the following from yourCochlear Implant Center (CI Center):

• Select a CI Center you are comfort-able with. CI’s are complicated.Well-informed, confident parentsmake the best decisions. Parents,referring audiologists, teachers andtherapists need to feel comfortableasking their CI center questions andgetting answers they understand.Before making our choice we inter-

viewed every implant center andschool for the hearing impaired inthe NY tri-state area. The extraeffort was well worth it.

The initial activation of a CI can bescary for a child. Ryan developedan aversion to the mapping room, asmany toddlers do. Luckily, Ryanhad established a strong relation-ship with our implant team. Whenhis aversion to the mapping roombecame more pronounced, our CIcenter allowed us to come early &play in the mapping room.

• Adjust maps to address specificspeech errors. Our auditory verbaltherapist regularly gives me a list ofspecific speech errors to give ouraudiologist when mapping. Forexample, Ryan’s intelligibilitydecreased dramatically as we beganto work on more complex sen-tences. He could hear specificsounds in isolation, but would losethem in connected speech. Afterthe audiologist finished gatheringinformation for the new primarymap, additional maps with a high,medium and low frequency boost,were developed. If we worked ‘s’endings in therapy we switch to themap boosting high frequency.These timely map adjustmentsallowed Ryan to acquire targetsounds much more quickly.

• Assist with placement decisions &IEPs. The educational coordinatorfrom our CI center was invaluablein giving us the confidence to makeRyan’s primary placement a main-stream one. Ryan had started 3-year-old preschool with 2 place-ments each day: am and pm. Hewas in tears daily because he wasso exhausted. Our educational coor-dinator observed Ryan in bothplacements, provided a reality

Ensuring Success for Children with Cochlear Implants:What Every Audiologist Should Consider

FT 11

check, a sounding board and a fontof wisdom.

• Practice play audiometry at homeAdvise parents to practice mapping& sound booth skills at home, makinga game of it. We started at 18 monthsduring Ryan’s implant candidacyperiod. Even at 4.5 years old, Ryangets better maps if we practice a fewtimes at home during the week beforeeach appointment.

Enabling a hearing impaired child toflourish in the mainstream is a longjourney. Early decisions can dramati-cally improve a child’s ability to thrivein the hearing world. If parents were

to understand the profound signifi-cance of brain plasticity and the direconsequences of procrastination mostwould opt for an aggressive manage-ment plan such as ours. In order tomake good decisions for their childrenand families, parents deserve honestand timely information. Each familywill then navigate its own path. Whilesome parents can sail solo in fairweather, it takes a multi-disciplinary,team approach to get us through theinevitable and frequent storms.

The author lives with her husband, andthree children, She can be reached at CMS@sahib.com.

1 Flexer, Carol. (1994, 1999). Facilitating Hearing and Listeningin Young Children. Singular Publishing Group.

2 Flexer, Carol, Richards, M.A. (January 1998). We Can Hearand Speak: The Power of Auditory-Verbal Communication forChildren Who Are Deaf or Hard of Hearing. Alexander GrahamBell Association for Deaf

3 Sindrey, David. (2003) Listening Games for Littles. WordplayPublications.

Donna L. Sorkin, MCP

For many deaf and hard-of-hearing peo-ple, the workplace poses the most diffi-cult communication challenges.

Multiple speakers in diverse environments,ranging from the telephone to meetings innoisy conference rooms to social events indark restaurants to presentations in largereverberant spaces-present a constantlychanging set of listening difficulties for any-one with a hearing loss. Workplace settingsare also complicated because the personwith hearing loss is concerned about howhis co-workers perceive requests for specialaccommodations. Speaking from personalexperience, I found that when my own hear-ing underwent a marked change as a youngadult pursuing a career, work was by far themost complicated part of the hearing losspuzzle to piece together.

Audiologists have a valuable role to play inaiding patients who have recently received acochlear implant with job-related transitions,whether the individual is re-entering theworkforce because of their improved abilityto communicate via a CI, or is someoneremaining in a job they held prior tocochlear implantation.

Depending upon the audiologists time com-mitments and comfort level in gettinginvolved with patients outside of the clinic

setting, this assistance can take any numberof forms. At a minimum, counseling andwritten materials can be provide andpatients can be encouraged to use these tolet his co-workers know what to expect andalso how they can help. Another optionwould be for the audiologist to visit theworkplace to serve as a resource and meetwith those people with whom he works withon a regular basis. A third possibility is tosuggest that the individual ask an advocatefrom their CI manufacturer to accompanyher to a brownbag lunch or other informalopportunity at work. Regardless of whichapproach the person selects, make availablevideos and written materials for the personto distribute to co-workers.

The Five Golden Rules 1. Setting Appropriate Expectations. Althoughoutcomes with cochlear implants haveimproved steadily over the past ten years, thereis still variability in how individual recipientsperform and also how long it takes for eachperson to maximally benefit from the technolo-gy. Often, an individual’s excitement about thetechnology leads co-workers to expect a dra-matic and immediate improvement in hearingoutcomes. Although such rapid changes some-times occur, we should always counsel recipi-ents to expect their hearing to improve slowlyover a 3 to 6 month period, or even longer.

The New Adult Cochlear Implant Recipient

FT 12

Give the person the background he or sheneeds to explain the process of learning tohear with a CI to her co-workers.

2. Promote use of listening therapy.Auditory verbal therapy (or other listen-ing approaches) are commonly recom-mended for pediatric CI patients but mayalso be helpful for adults who receivecochlear implants-depending upon theirduration and history of deafness. Suchstructured listening programs can take anumber of forms such as one-on-onetherapy, a computer-based program, orsome other method. Particularly if theindividual is not “surrounded by sound”at work or at home, adults should beevaluated for listening therapy.

3. Encourage use of assistive devices. Evenexperienced “star” CI performers some-times face difficult listening situations andneed the extra help provided by assistivelistening devices. With the wide varietyof convenient technology – somedesigned to interface directly with a CI,there is no excuse not to make use of suchdevices. If the person had little open-setspeech discrimination prior to implanta-tion, he probably was not using assistivedevices and may need a gentle nudge totry them out. Keep a loaner device in theclinic for patients to borrow to see if theywant to pursue assistive devices further.

I attended a conference on classroomacoustics that was held, ironically, in ameeting facility with horrible reverbera-tion. At the first break, I gave the speakermy microphone to wear and attached thereceiver to the back of my ear levelspeech processor. I listened comfortablyto the remaining lectures while the peo-ple with normal hearing struggled tounderstand the speakers. An assistive lis-tening device that aids communication inthe workplace is a “reasonable accommo-dation” under the Americans withDisabilities Act (ADA). Hence, the recipi-ent could ask his or her employer to pur-chase a device for use at work.

4. Help your patient participate in the telecom-munications revolution. If the new CI recipi-ent has not been using a voice telephone, itmay take time (and some encouragement)for him to regain this valuable workplace

skill. Recommend that he practice at homewith a patient, “safe” speaker before heattempts any work-related phone use.Demonstrate the various options (e.g., tele-coil, direct linkage to the phone, acousticcoupling) and discuss the pros and cons ofeach. Ask a CI company advocate to pro-vide details on how to use the variousperipherals that connect the cochlearimplant to telephones.

Be sure to tell the patient that even themost successful CI users have prefer-ences among the various models ofwired or wireless telephones. I haverelied on my favorite “work” telephonefor 10-1/2 years through three differentjobs – my telephone comes with mewherever I go. My employers haveassisted by adapting the office tele-phone system to accommodate my oldAT&T “clunker,” which is still my pre-ferred telephone.

Many employers now purchase wirelessphones and pay for service contracts foremployees, if the phone is needed for thejob. When the CI recipient progresses tothe point of being able to use a wirelessphone, encourage her to test activatedphones before committing to a contract;there are substantial differences in howvarious phones perform for someonewith a cochlear implant. Keep a list ofthe makes and models of wireless phonesthat work best with cochlear implants.(In general, if a phone works well forhearing aid users, it will also be a goodchoice for someone with a cochlearimplant.) Some cochlear implant usersbecome quickly discouraged because thefirst wireless phone they try doesn’t workfor them. Encourage your patients to tryvarious phone options and also talk toother CI recipients who use cell phones.

My own favorite telephone accomplish-ment was the successful completion ofmy first conference call. Because confer-ence calls became commonplace after Ilost my hearing, I had never participatedin one before I had a cochlear implant.Conference calls can be overly challeng-ing if participants interrupt each otherwhen they talk, or if participants are par-ticipating via a conference phone andeveryone does not speak directly into the

microphone. Encourage your patient toset ground rules so that call participantsknow what they need to do to help her.

5. Emphasize the importance of having a hear-ing “buddy” at work. Even with the marked-ly improved speech discrimination enjoyedby most cochlear implant recipients, as withanyone with a hearing loss there will besome occasions when even the most suc-cessful CI user misses information. Helphim to realize that just because he has diffi-culty in some situations, does not mean heis not doing well with his CI. Rather thanbluffing, encourage him to take a proactivestance in every aspect of communicating atwork. Having a hearing buddy helps inany environment-including the workplace.Further emphasize using typical copingstrategies employed by people with hear-ing loss, such as paraphrasing or othermethods of confirming verbal discussion.

These are five strategies for helping acochlear implant recipient make a positiveadjustment in the workplace and certainlythere is other guidance that you might alsoprovide. Perhaps the most important gen-eral advice you can give your new CIpatients in the workforce is to combine theopportunities afforded by improved hear-ing with a renewed look at attitudes andpractices that make sense for anyone in theworkforce-pursuing training to improveskills, seeking challenges, and developingpositive relationships with co-workers andothers. After all, it is the individual’s ownefforts and the way he or she relates toothers that most impacts on one’s achieve-ments. A cochlear implant may help aperson to be more confident and relaxedabout his or her abilities but it is an indi-vidual’s own efforts, irrespective of hear-ing loss, that determines success in theworkplace and in life.

Donna Sorkin, MCP is Vice President,Consumer Affairs at Cochlear Americas. Shehas been an enthusiastic cochlear implant usersince 1992.

FT 13

Kristine Rafter, MA

Each cochlear implant company has amission statement, clearly directedtoward improving the quality of life

of each individual who can benefit froma cochlear implant. The primary com-mitment of the manufacturer, assuring alifetime of service and support, isaccomplished most often through theclinical, technical, and customer serviceteams who are the most frequent liaisonsbetween the recipient and the manufac-turer. Although sometimes quite remotefrom the user, engineering, software,research and development teams, andreimbursement specialists advocatingfor a successful insurance environmentfor both service providers and individu-als, provide a significant contribution tosuccess at all spokes of the cochlearimplant wheel.

So how do we make a successful connec-tion between the manufacturer and eachof the other professionals and caregiversinvolved with the cochlear implant recip-ient? Educational backgrounds, commu-nication biases, and previous exposuresto other cochlear implants vary widelyamong those surrounding each cochlearimplant recipient. Mutual recognition of,and respect for, the sincerity of the manu-facturer and its representatives, the audi-ology team, the surgeons, the speech-lan-guage pathologists, the educators, thetherapists, the (re)habilitationists, thepsychologists, and the family and friendsare the bases of the successful connectiongeared to optimize the experience of thechild, or adult, with a cochlear implant.Each participant brings input and opin-ion that must be valued and consideredby all others. There is not a single personinvolved with a cochlear implant recipi-ent who understands all aspects of thetechnology, the programming, the aca-demic or intellectual skill, learning style,communication style, auditory historyand development, social history andstyle, family dynamic and other challeng-ing conditions and medical concerns. Asa team, a cohesive team, there is anopportunity to be successful.

For the manufacturer, representativeswork at developing relationships withthe cochlear implant specialists in theirregional communities. The primary focusis the implant center and the implant cen-ter audiologist because most other con-nections stem from that individual. Howare these regional teams organized?There are likely differences from onemanufacturer to another, but essentiallythe map is divided into regions.

The regional teams are composed prima-rily of experienced cochlear implantaudiologists, and supported by cochlearimplant users and, in some cases, educa-tors. Additional staff based at the homeoffices supports the regional teams.Along with educational teams based atthe home offices, these well-trained andexperienced field representatives provideintroductory level and advanced leveltraining on cochlear implant candidacy,counseling, theory and programming.Additional topics include troubleshoot-ing, use of assistive listening devices andrehabilitative methods. Training may bedelivered in the form of group work-shops held at the manufacturer’s homeoffice, within the region, or at the center.

Presentation of manufacturer research,customer research, and changing trendsin cochlear implantation around the con-tinent are key to advancing the field.These events are often coupled with larg-er cochlear implant gatherings attractingcochlear implant service providers withdifferent backgrounds, practicing in dif-ferent parts of the world.

Manufacturers provide technologies,support and oftentimes research-support,for those cochlear implant teams interest-ed in augmenting their clinical workwith cochlear implant research. In thisway, the manufacturers contribute to thescientific advancement of cochlearimplants, again with the ultimate focuson the individual.

The primary liaison between the manu-facturer and the cochlear implant audiol-

ogist is the clinical specialist. Clinicalspecialists provide on-site assistance withpatient programming, installing, upgrad-ing, and training in software, and demon-strating and troubleshooting new hard-ware. In most cases, clinical specialistswill attend any first-time event for acochlear implant audiologist.New audiologists and other cochlearimplant professionals continue to enterthe field and require training. That is thegood news. Many leave for private prac-tice, raise families, pursue other careers,or to join the manufacturers. The chal-lenging news is that there are insufficientnumbers of cochlear implant specialiststo meet the demand for current, and like-ly future, needs. For this reason, and toassure quality cochlear implant servicesin the future, the cochlear implant manu-facturers participate in the support ofcochlear implant training at programsacross the country.

Research has demonstrated that pro-gramming expertise and creativity con-tributes to user success and satisfaction.Clinical specialists are frequently calledto assist with challenging cases and forthose whose performance is in question.The clinical specialists, often supportedby technical engineering specialists, pro-vide diagnostic measures designed tooptimize fittings. In some cases, thor-ough testing may identify the recommen-dation for reimplantation. While our clin-ical and technical support persons per-form their services with passion andcommitment, the manufacturer is not aclinical service provider. Medical, clini-cal, and rehabilitative services are provid-ed by hospitals and clinics. Our clinicaland technical support is made availableat the request of the clinician, or cochlearimplant center.

Comprehensive pediatric cochlearimplant programs have educational con-sultants in place to act as the liaison per-son for the young cochlear implant recip-ient or student. These staff persons arecommitted individuals and play a centralrole in the success of a young cochlear

The Cochlear Implant Manufacturer:Collaboration and Customer Focus

FT 14

implant recipient in the community and in theschool. For implant center educators, speech-language pathologists, teachers of the deaf andhard-of-hearing, auditory-verbal therapists,and other habilitationists and rehabilitation-ists, a variety of services are now being offeredto support their efforts within the range ofeducational settings currently providing serv-ices to cochlear implant students of all ages.

Each manufacturer is involved in the reim-bursement process to assure access to technol-ogy for as many individuals as possible. Ourroles are key to all those providing services tocochlear implant candidates and recipients,and to the majority of individuals who chooseto receive cochlear implant technologies whowould not be able to do so without consider-able contribution from insurance.

Manufacturers are involved at the policylevel by advocating for appropriate cover-age and reimbursement by Medicare,Medicaid and private insurers. While con-siderable in commitment and depth, thisaspect of the manufacturers’ activity mayoften go unnoticed by the majority of thecochlear implant community.

Our participation that has the highest profile,is most requested, and perhaps, most appreci-ated, occurs at the claims level. Manufacturershave highly trained, dedicated, and tenaciousstaff persons who provide assistance to centersand individuals in obtaining coverage andpayment from public and private insurancecarriers. For an individual, this involvementmay begin at the time one begins to consider acochlear implant, follow through the assess-ment and pre-certification process, for surgery,and for post-operative programming and reha-bilitation. As hardware needs replacement, wemay assist with gaining coverage for the moreincidental, but ongoing maintenance costs forreplacement cables, headpieces and recharge-able batteries. As technology progresses andnew sound processors become available, par-ticularly those that can provide better hearingin more diverse listening situations, the manu-facturers’ reimbursement teams play a valu-able role in assuring success.

What about the individual? How does themanufacturer provide support? In addition toproviding continuing education and supportto the professionals working with the cochlear

implant recipient, the manufacturer providesdirect support to the user. The manufactureris accessible to the candidate, user, family andfriends via a number of pathways includingvoice phone, TDD, email, websites, printedmaterials, videotaped materials, and regionalvolunteers. Audiologists are available via atoll-free number and users via email.Websites cover most of the hot topics and fre-quently asked questions regarding cochlearimplant technologies. Supplies may beordered by contacting customer service spe-cialists on the phone or by accessing cata-logues included in the websites.Manufacturers respond to inquiries regardingtechnology, candidacy, locating cochlearimplant centers, reimbursement, troubleshoot-ing, educational issues, therapies, assistivedevices, and performance concerns.

The primary contact, though, should be thecochlear implant center. Whether a candidatein research mode, or an existing user with con-cerns, the manufacturer believes that thecochlear implant professionals familiar withthe individual are the best source for reliableinformation and guidance.

How do the customers assist the growth andsuccess of the cochlear implant manufacturer?Manufacturers have learned an important les-son. First and foremost, it is necessary to lis-ten to the cochlear implant recipient, the userof the technology, to plan, prioritize anddevelop new products and services. As thediversity within the cochlear implant recipientpopulation expands, the demand for newaccessories and interest in more specific andchallenging listening environments will bea-con the manufacturer to create and market theright products, that is, if we continue to listento the customer.

Those of us involved in cochlear implantsunderstand that the best outcome for those weserve is born of a collaborative effort. Attimes this may be daunting, at times exciting,and within the medical community quiteunique. It is an ever-expanding circle of indi-viduals who work hard, ponder long, andshare joys together.

Kristine Rafter, MA is a clinical audiologist, and acochlear implant audiologist, currently serving asthe Advanced Bionics Northeast Regional Director.

FT 15

On February 5, 2003, the US District Court ofNew Hampshire upheld a NewHampshire Department of Education

Independent Hearing Officer’s decision that thelocal school district was responsible for provid-ing cochlear implant mapping services[Stratham Sch. Dist. v. Beth and David P., 103LRP 4317 (02-135-JD, 2003 DNH 022)]. Based onthe premise that the child could not benefitfrom his educational program without hiscochlear implant being properly mapped, thecourt ordered that the district reimburse theparents’ mileage to the mapping center (100miles away) as well as pay their insurance co-payment for the mapping service provided bythe implant center audiologist.

This decision was based on the followingpremises: Because the child’s present mode of commun-ication involved the use of the cochlear implant,the cochlear implant had to be mapped for edu-cational benefit.

Mapping was a related service under audiolo-gy; audiology services cited in IDEA were notintended to be exclusive [34CFR300.24(b)(1)].

Mapping services were not a “medical” relatedservice because they were not provided by aphysician in accordance with the definition inIDEA of medical services [34CFR300.24(b)(4)].

Audiology as a related service was the core ofthis case. The parents wanted audiology servic-es on their child’s IEP to assist their child inbenefiting from special education. They con-tended that mapping services were included aspart of audiology services. Further, since theschool district did not employ a “speciallytrained” audiologist to conduct the mappingservices, the parents requested that the districtpay for the audiology services as well as thetransportation costs to the implant center toreceive them.

Other significant points in the testimony ofthe initial hearing and subsequently consid-ered in the appeal include:

The school district acknowledged the parent’schoice in mode of communication and devel-oped the child’s IEP to support auditory/oralcommunication. In doing so, the district con-tracts with a private, specially-designed

auditory-oral preschool where he receives serv-ices from a speech-language pathologist anddeaf education teacher. He attends the district’sspecial education preschool in the afternoon.

The school district agreed that it was responsi-ble to make sure that the implant was function-ing and included this service in the IEP. Theyargued, however, that the actual mapping was amedical service, because the implant could notfunction without being mapped, and, therefore,it was not a related service under audiology.

The school district did not include audiologyservices as a related service on the child’s IEP,because they felt that mapping was a medicalservice. However, the school did offer to payfor an annual audiological evaluation andupdate that would exclude the actual mappingof the cochlear implant.

The audiologist who testified on behalf of theparents was employed by the manufacturer ofthe child’s cochlear implant. She stated that “inaddition to mapping services, the audiologistmust provide sound field testing to track speechperception and should be in communicationwith the educators and family to insure that theimplant is working and programmed best to fitthe needs of the child, and that if the school hadan audiologist on staff, there would be no needto take the child to the implant center.”

The district argued that the implant was not ahearing aid nor an assistive technology devicebut rather a life-long device that was neededoutside of school as well as in school. The audi-ologists testifying for the district described acochlear implant “as an electrical deviceimplanted to stimulate the auditory nerve. It isnot an assistive learning device. It is an artificialsense organ. Mapping is an adjustment of elec-trical current levels to a surgically implanteddevice and is not a form of habilitation.” Theaudiologist testifying on behalf of the parentsstated that the implant was not strictly a med-ical device but “also an educational devicebecause it is tied to a cognitive function.”

The district also argued that the cochlearimplant was not a covered device and service,because neither IDEA, nor its regulations, iden-tified it as such under the context of an aid, oracoustical hearing aid.

Commentary:Court Ordered Cochlear Implant Mapping

Cheryl DeConde Johnson, EdD

Originallypublished inEducationalAudiologyReview, 20:2,pp12-15, 2003.

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In response to the district’s concernregarding potential implications forschools beyond mapping services forcochlear implants, or services for otherbiomedical devices, the parents speci-fied that they were only seeking map-ping services.

QUESTIONS/IMPLICATIONS RAISEDBY THIS DECISION

Can the cochlear implant operate withoutbeing mapped? If not, is the processor anextension of the surgery required to makethe device function?

While this case limited its request tomapping, will schools also be required toprovide the processor, software upgrades,and related parts to maintain the deviceso that the child can receive benefit fromhis/her educational program? Could thismean the external components of theimplant are considered “educational”and separate from the implanted portion?

If mapping is required for the child toreceive educational benefit, it can be con-strued to be an educational service. Sincemost educational services are provided atschool, should schools be required to pro-vide it as part of their routine on-siteaudiology services? Can the school deter-mine who provides these services as longas the audiologist is qualified? Whodefines “qualified” audiologist? Areschool audiologists prepared to under-take the special skills necessary to pro-vide mapping services?

Although poorly reimbursed, mappingservices are currently covered by insur-ance. Can the school bill the insurancecompany if its audiologist provides themapping service?

Schools are currently required to insurethat hearing aids used in school are func-tioning properly. For personally-owneddevices, does “insure” mean the identifi-cation of problems and notification ofparents so that programming or repairscan be made by the dispensing audiolo-gist, or does it mean that the school isalso required to provide the program-ming and make the repairs? For person-ally owned devices, most schools provideservices that include electroacousticanalysis of the hearing aid, real ear meas-urements and/or listening checks. Theyusually perform troubleshooting servicesthat include minor hearing aid repairs

such as replacing batteries and unclog-ging earmolds. The common practice isto notify parents of other problems sothat the hearing aid can be taken by theparents to the dispensing audiologist forrepair at the parents’ expense. Shouldn’tthe responsibility for cochlear implantsbe treated the same? In doing so, I believethat most school programs currently con-duct daily listening checks of the implant,replace coils, and perform auditory andspeech perception measures to evaluatethe effectiveness of the cochlear implant.However, when problems are identified,the audiologist notifies the parent andrefers the child back to the implant centerfor mapping or other services.

This case decision only discussed educa-tional “benefit” while IDEA specifiesservices that provide “reasonable educa-tional benefit.” How does this differenceapply to cochlear implant performance?

As a personal device required 24/7, howdoes the cochlear implant compare to apersonal hearing aid? Are schools alsoexpected to provide hearing aids forhome/personal use 24/7 outside of thedefinition of assistive technology?

Must mapping services be providedwhen school is not in session, e.g., duringsummer? What about infants and tod-dlers under Part C?

DISCUSSION

As one can imagine this ruling couldhave significant implications for schoolaudiology services. Some issues I believewe must consider are:

Personal vs Medical Device. Cochlearimplants are medical devices and map-ping is required for the device to func-tion. As an implanted device it is part ofthe child and utilized 24/7. As such, asan educational device anymore than apacemaker required to keep a heart beat-ing or the school dispensing insulin todiabetic children.

Insurance. We have all experienced thedeclining coverage of insurance. Lack ofhearing aid coverage has been particular-ly frustrating and even though cochlearimplants are included in most policies,the coverage is often far less than the costof the device, surgery, mapping, andrehabilitation or habilitation services.Coverage for speech therapy and other

related services has decreased significant-ly, because insurance companies knowthat schools must provide these servicesunder IDEA. Decisions such as this onefurther erode the insurance company’sobligation to provide necessary cochlearimplant follow-up. Parents need to clear-ly understand expectations for follow-upappointments and covered services.These provisions need to be detailedthroughout the pre-implant process.Implant centers must continue to billinsurance companies. Manufacturersshould continue to aggressively educatereimbursement officials regarding neces-sary cochlear implant services and reim-bursement rates. If schools provide map-ping services through their audiologists,they must be prepared to bill the insur-ance companies for that service.However, doing so still does not negatethe risk that insurance companies willview this as an educational service, there-by limiting or eliminating mapping as acovered service.

School Resources. School resources arelimited. The federal government onlypays for about 12% of special educationcosts; state and local school districts paythe balance. Therefore, this decision putsfurther stress on education programs thathave limited resources. If one child getsmore services, another usually gets less.But if it is “the law”, insurance compa-nies, advocacy groups, implant centers,and parents know that schools must pro-vide the service. Schools cannot denyservices as insurance companies are ableto do. Schools also need to be carefulstewards of taxpayer money, and taxpay-ers will not be happy to learn that schoolsare now required to maintain medicaldevices, pay insurance premiums, andfunction as defacto insurance policies. Inmy opinion, schools should not be the“payer of last resort” for costs that are notspecifically tied to educational benefit.However, because most schools are notprepared to provide mapping services in-house, most will like bear the cost ofsending children to implant centers.

Role of Advocacy Groups. Advocacygroups provide parents with informationand support to obtain appropriate servic-es for their children who are deaf andhard of hearing. As a professional andparent, I have always been a supporter ofthese programs and continue that role as

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a board member of a national parentorganization. However, I believe that atleast one organization, AG Bell, has takenthis program too far. AG Bell’s EducationAdvocacy Program coaches parents toobtain AVT-certified therapists for theirchildren in schools and as well ascochlear implant mapping services. Thestated goal of this program is “to pursuetest cases in order to set legal precedencefor appropriate educational services”(Volta Voices, Jan/Feb 2003, p. 4). Theyemploy a legal service and may even pro-vide funding to support families in thisgoal. AG Bell filed a “friend of the court”brief in support of this case. AG Bellattorney Arthur Ackerhalt was quoted inthe Portsmouth (NH) Herald stating,“We’re very please with the result. This iswhat we advocated for when we filed thefriend of the court brief. We believe it’sthe correct legal decision” (Feb 15, 2003).

While these services may help individualchildren, they are not changing the edu-cation system in a positive way. I recog-nize and fully support the need for majoreducation reform if we are to improveoutcomes for all deaf and hard of hearingchildren, including those who are oraland who use cochlear implants. But whois looking out for the children of familieswho do not have the ability or resourcesto assure services? The employment ofAVT-certified therapists and provision ofmapping services will not change the sys-tem. Instead, these misguided practicesby AG Bell may result in further alien-ation of schools and school professionals.Rather, we should be using our resourcesto train our teachers and therapists inschools in appropriate techniques to max-imize auditory and communicationdevelopment, whether it be with a hear-ing aid or an implant. To their credit, AGBell does have a Program AssistanceProject under their Public School Caucusthat is beginning to provide this type ofsupport. However, as an AG Bell pro-gram it is limited to programming fororal children even though the trainingcould also strengthen auditory skill andspeech development for children in sim-com/total communication programs.

Liability. Implant centers recognize andaccept the liability associated with med-ical devices. If schools begin altering amedical device that has been surgicallyimplanted, what are the potential liabilityconsiderations for both the school and

the implant center? I do not think parentsfully understand the importance of con-tinued monitoring and mapping throughthe implant center, nor do they alwaysrealize that this will be a life-long require-ment for the cochlear implant to functionproperly. Further issues arise when fami-lies move and require services from cen-ters where their children were notimplanted. Parents must be made awareof and accept this responsibility as theirown prior to implantation.

IDEA. Is it time to revise the definition ofaudiology and proper functioning ofhearing aids in IDEA to include cochlearimplants but also to delineate the respon-sibilities of parents and the educationsystem in providing services for thesedevices? IDEA reauthorization is occur-ring right now. We have an opportunityfor action.

The Future. I recognize the critical necessi-ty of appropriate mapping for children tobenefit from their cochlear implants. I amin favor of schools working with cochlearimplant centers to facilitate mapping serv-ices. Presently, these services includedevice troubleshooting and sound fieldand speech perception assessment todetermine that the implant is providingappropriate stimulation for the child andnotification to the implant center when itis not. We know that distance from thecenter for many families is a significantbarrier to adequate follow-up. However,these issues need to be addressed andsolved during the pre-implant process. Ido believe that many school audiologistscan and will provide mapping services inthe future. Before this can happen howev-er, technology must be refined, equipmentand software must be available, trainingmust be provided, and experience mustbe gained. Tele-medicine for remote map-ping holds promise as an important stepin this process.

I also believe that mapping should not bea required service, but rather one thatschool districts could offer should theyhave the resources to do so. It is appro-priate for schools that specialize in pro-gramming for students with cochlearimplants such as Central Institute for theDeaf, Clarke School for the Deaf, and St.Joseph Institute for the Deaf, as well aslarge urban public school programs, to beable to offer these services. However,most of these schools are private, not

public ones. As private schools, they areable to bill insurance for these servicesjust as implant centers do.

ACTIONS YOU CAN TAKE1. Establish a forum for communication.

Audiologists in schools and in implantcenters need to talk and, together, dis-cuss this issue with parents as well aslocal and state parent advocacygroups. Everyone needs to own up totheir responsibilities. Professionalorganizations also need to carefullyconsider what they tell parents in theireducation and advocacy training.Manufacturers have a responsibilityby letting implant centers and profes-sional organizations know that theydo not condone this practice.

2. Discuss this case with your schoolspecial education administrators andstate department of education offi-cials. Ask them to provide input toIDEA reauthorization to exclude serv-ices for biomedical devices, specifical-ly cochlear implant mapping. Talk toyour school district and state legalcounsel about this issue. Help them beknowledgeable should a case arise.

3. Write a letter to AG Bell explainingyour concerns. Copy your letter toyour local implant centers, implantmanufacturers, national and stateprofessional organizations, local andstate parent advocacy groups, andanyone else you feel needs to beaware of this issue.

In closing I would like to applaud theefforts of the Stratham, New Hampshire,School Board in their decision to fightthis issue on principal. For a very smallschool district (about 600 students) itwas a costly and time-intensive invest-ment. It would have been much easierfor them to pay the fees for mapping andtransportation for this student. Theydeserve an award for attempting to pre-serve the integrity of “educational servic-es” and for recognizing the implicationsof this decision.

Cheryl DeConde Johnson, EdD, is with the Colorado Department ofEducation, Denver, CO.

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Commentary:Response to DeConde Johnson

Iam in receipt of your letter dated March8, 2003 regarding the Hunter P. case.Although I understand your concerns

about the effect of Hunter P., let me sharewith you a somewhat different perspectiveof the case and its impact under the IDEA.

The Alexander Graham Bell Associationfor the Deaf and Hard of Hearing estab-lished an Educational Advocacy Program(EAP) for the purpose of promoting andadvocating the rights of students who aredeaf or hard of hearing, under the IDEA,to a Free Appropriate Public Education(FAPE). This came about because of thehundreds of calls to AG Bell every yearfrom parents of oral deaf and hard of hear-ing children. Although we know there aremany school districts that do a fine job,sadly there are too many parents who havebeen unable to secure an appropriate pro-gram to meet the needs of their children.

AG Bell filed an amicus curiae (friend of thecourt) brief with the New HampshireDistrict Court in support of the hearingofficer’s decision requiring the StrathamSchool District to pay for the mapping of achild’s cochlear implant (over and abovethe payments from the parents’ healthinsurance carrier). AG Bell’s amicus curiaebrief emphasized the necessity of mappingin order for Hunter to benefit from hiseducational program since his IEP wasbased on oral communication. Without theproper mapping, Hunter would not beable to understand classroom instructions,participate with his peers in class, oradvance in an educational setting. In par-ticular, AG Bell was, and is, concerned thatthe impetus of the IDEA, which is to pro-vide meaningful access to an education forchildren who are identified as “disabled,”applies to all children, including childrenwho are deaf or hard of hearing.

The legal issue underlying the Hunter P.decision was a narrow one, i.e., whethermapping services by an audiologist is a“related service” as defined in the IDEA.Under the federal law, “related services”include “transportation, and such devel-opmental, corrective and other supportiveservices (including audiology services.) asmay be required to assist a child with a

disability to benefit from special educa-tion.” At the hearing level, the school dis-trict’s own witness (certified as an expert)testified that if the cochlear implant werenot functioning properly, Hunter couldnot access information auditorily norcould his IEP be implemented.

All the Hunter P. case does is apply thelaw already in existence to providemeaningful access for a child with ahearing loss. This decision is not anexpansion of the law, but rather a modestapplication of what Congress and thecourts have said must be provided forchildren with disabilities.

The U.S. Supreme Court, following theintention expressed by Congress, hasbroadly interpreted “related services” tocover a non-exhaustive list of servicesrequired in order for a child with a dis-ability to benefit from special education.In particular, the Supreme Court in CedarRapids Community School District v.Garret F., 526 U.S. 66 (1999) and in IrvingIndependent School District v. Tatro, 648U.S. 883 (1984) respectively held that theIDEA requires a school district to providea ventilator-dependent student with afull-time nurse and to provide the servicesof in-school catheterization, even thoughthese services are not explicitly stated inthe federal regulations. The Court distin-guished “related services” from “medicalservices” which it explicitly defined asthose services provided by a physician,and concluded that any service by a non-physician will not be considered medicaland would be eligible as an educationallyrelated service. The Supreme Court creat-ed “a bright line test” to distinguishbetween medical services and relatedservices: services provided by a physicianare medical and services provided by anon-physician are not medical and are eli-gible as educationally related services.

You mention that a cochlear implant is a“medical” device and ask if mapping acochlear implant is any different than aschool district’s obligation to monitor apacemaker or to dispense insulin to achild with diabetes. The answer (accord-ing to the United States Supreme Court)

is that if monitoring or dispensing ofinsulin can be performed by a nurse orother non-physician, it likely would be a“related service.” In fact, many insulin-dependent children throughout the coun-try now have nurses not dispensinginsulin, but administering it. To do oth-erwise would deny those children theopportunity for meaningful access to anappropriate education.

An apt comparison to mapping would bethe typical example of a child who has aprosthetic limb. The school district is notrequired to pay for the cost of the artificiallimb, any more than it is required to payfor the cost of a cochlear implant (whichwas not requested in Hunter P.). If physi-cal therapy to enable the child to functionbetter with the prosthesis and theimpaired limb were required to addresseducationally related concerns, physicaltherapy would be a “related service.” If aphysician were needed, such serviceswould be considered “medical” and notthe responsibility of the school district.

If a child with juvenile diabetes has aninsulin pump that fails and the schoolnurse is capable of correcting a problemwith the pump, she could, and should,do so as a “related service.” If a physi-cian were required, such services wouldbe considered “medical” and would notbe required nor reimbursable. A schooldistrict would not be required to pay forthe insulin pump (nor were Hunter’sparents requesting payment for thecochlear implant).

You also mention that a cochlear implant,as an implanted device, benefits a childall of the time, even outside of the educa-tional setting. However, the IDEA hasalways covered services that provide ben-efit outside of the educational setting, aslong as those services are necessary forthe child to benefit from special educa-tion. For example, if a child has a pros-thetic limb, that child would be eligible toreceive physical therapy at the expense ofthe school district, even though the pros-thetic limb is used at home as much as itis used in school. Also, please note that,unlike the services related to a prosthetic

K. Todd Houston, PhD

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device, insulin pump, or a tracheotomy tube,the mapping of a cochlear implant relatesdirectly to permitting a child meaningfulaccess to an education.

You also point out that schools are currentlyrequired to ensure that hearing aids used inschool are functioning properly and askwhether schools are also required to repairhearing aids (other than routine adjustments ortrouble shooting). School districts are not (andshould not be) required to repair hearing aids,nor are they required to repair prosthetic limbsfor students (who are entitled to physical thera-py) or pay for surgery related to children onventilators (who are entitled to nursing servicesin school). Likewise, school districts should notbe required to “repair” a cochlear implant,which was not at issue in Hunter P., but map-ping is not a repair, it is a routine adjustment.

You also point out that school resources arelimited. Indications are, however, that the pro-vision of mapping services will not cost schooldistricts much money. In the case at hand, par-ents only asked the district to pay the portionof the cost not covered by health insurance,which was $10.00 per visit, and the cost oftransportation to and from such appointments.Because implant surgery costs tens of thousandof dollars, it seems likely that few individualswithout health insurance (private insurance orMedicaid) would undergo such surgery.Consequently, it seems likely that most chil-dren who have had implant surgery wouldhave health insurance that covers most of thecost of mapping services.

Also, you state that schools should not be the“payer of last resort” for costs that are “notspecifically tied to educational benefit.”However, the law requires that a school dis-trict pay for catheterization services and evena full-time nurse for a student on a ventilatorand must do so as an educationally relatedservice. Yet, you would suggest that a schooldistrict should not be required to providemapping services for a child whose IEP pro-vides for an oral mode of communication, andthe “educational benefit” is obvious! We arenot unmindful that school districts have limit-ed resources, but at the same time, we aremindful that children who are deaf or hard ofhearing are entitled to the same services underthe law, which are permitted and being pro-vided to students with other disabilities. Inshort, students whose disabilities involve deaf-ness or hard of hearing should not have a“second class” disability within the meaningof the IDEA.

You also suggest that there is a “risk” thatinsurance companies will limit or eliminatemapping as a covered service. Yet, since incep-tion of the IDEA, school districts have formany years routinely accessed third-partypayors for other related services such asspeech therapy. In any event, the “risk” of notrequesting services for children who are deafor hard of hearing, notwithstanding that suchchildren are entitled to services under the law,raises greater negative ramifications. If thelaw (as interpreted and implemented) requiresa full-time nurse for a child on a ventilator, alap top computer for a child with cerebralpalsy and sophisticated assistive technologicaldevices for a child with severe dyslexia, thewithholding of mapping services for a childwhose IEP is based on the use of a cochlearimplant would mean that children who aredeaf or hard of hearing are in effect entitled toa lesser FAPE than children with other disabil-ities under the law.

Lastly, you speak of the role of advocacygroups and express the belief that AG Bell is“misdirected” in its endeavor. I could not dis-agree with you more. AG Bell is advocatingthat children who are deaf or are hard of hear-ing should receive a Free Appropriate PublicEducation. Whether school audiologists aretrained and capable of performing mappingin-house (similar to speech therapy, occupa-tional therapy or physical therapy services) orwhether the school provides for such servicesby contracting with an outside audiologist,children who are deaf or hard of hearingshould be entitled to access mapping of acochlear implant, as a related service, as longas it assists the child to benefit from specialeducation. Parents have been clamoring foryears that they have nowhere else to turn inorder to access the services that their childrenare already entitled to under the law. AG Bellis advocating that the law should be fairly andproperly implemented.

K. Todd Houston, PhD is the Executive Director/CEO, Alexander Graham Bell Association for the Deaf and Hard of Hearing, Washington, DC.