Gloria Rodriguez-GilCalifornia Deaf-blind Services

53rd Annual CTEVBI Conference 2012

How the CI works. Candidacy criteria for CI (info from HEI) Mapping and AVT Preliminary findings of the research study

"Children Who Are Deaf-Blind with Cochlear Implants Project” (2004-2011).

Practical strategies to help the student benefit from the use of the CI

Three students who have CIs. Some resources available

A cochlear implant is a hearing device that is surgically implanted.

It transforms sound and speech into electric energy which stimulates the auditory nerve directly

A cochlear implant is very different from a hearing aid. Hearing aids amplify sounds so they may be detected by the parts of the ear that are not damaged.

Hearing through a cochlear implant is different from normal hearing and takes time to learn or relearn. However, it allows many people to recognize warning signals, understand other sounds in the environment, and enjoy a conversation in person or by telephone.

A CI will provide an aided audiogram thresholds between fifteen and thirty dB (normal to mild hearing loss).

Current FDA regulations children need to have a minimum age of 12 months.

They will do it younger if the child had meningitis or the child is at least 20 pounds (this is the anesthesiologist rule for elective surgery)

Have a severe to profound sensorineural hearing loss

In the past they said that they gave a CI if the child didn’t benefit from the HA. Now, is if the HA is insufficient to support continued auditory-oral development

Nowadays children can qualify for CIs even with a significant amount of measurable hearing if there is evidence to suggest that access to sound (specially in the high frequencies) will be limited

Now they do bilaterial CI’s or a CI in one ear and a hearing aid in the other.

No medical contra-indications The child has the support of an

education/therapy program that supports auditory/oral development

Strong support from the child’s family Reasonable expectations

HEI don’t only want to provide an implant so the child can hear. They want to provide an implant so support continued auditory-oral development

They have a research project where they are implanting a select group of children with additional disabilities looking for non-traditional benefits for CI

Does it improve their cognition, their behavior, they general connectedness, but not only to make them auditory oral communicators solely

Other facilities have different criteria It depends case by case (e.g., They would be

more incline to implant a child who is deaf who was loosing their vision).

They recommend that the minute there is any possibility that the child may benefit from the CI please make the referral.

Not long after the implant surgery, the recipient must get the implant mapped, or programmed so that new user can take in sound without pain and other discomfort. 

The audiologist will connect the implant to a computer and test the implanted electrodes

The audiologist will be seeking a sound "comfort level" for the implantee. The comfort level is important because at first, for some implantees things may sound "too loud."

Initial mapping is going to be using lower stimulation levels that they ultimately they will need.

Over several sessions they increase the stimulation and “find tune”.

As the child gets older they can provide them with more information.

In general, mapping is done several times the first year and after that once annually along with speech perception and speech/language evaluations.

The focus is to maximize the child’s listening skills so the child can learn to understand and develop spoken language as the child’s primary communication mode.

They understand the normal sequence of auditory development and address therapeutic techniques toward achieving these milestones: detection, discrimination of different sounds, identification of sounds/words, and then comprehension of more complex language, as well as expression of language.

AVT is provided one-on-one and the goal is that the parent becomes the child’s primary therapist so they apply what they learn in the AVT session in their daily life.

It is hard to find auditory AVT so the IEP team can request an SLT who use AVT techniques and has experience with children with CI

An SLT, a DHH teacher and an audiologist can get a professional certification as an AVT

An education specialist who visits schools and provides technical assistance related to the child’s CI and their language development

The Teacher Research Institute/Western Oregon University Kat Stremel Thomas & Mark Schalock

East Carolina University Susan M. Bashinski, Ed.D.

Cincinnati Children’s Hospital Medical Center Susan Wiley, MD & Charlotte Ruder, CCC

Overall, 4,291 children have a mod-severe, severe or profound sensorineural hearing loss

States increased their identification of children with implants from 251 in 2005, to 622 in 2010

An increased number of children are receiving bilateral implants

Total number of participants to date = 109 Of these 109, 17 are still pre-implant They have post-implant data on 92

children They have pre-post data on 23 children

Etiology Percentage

CHARGE Syndrome 29.4%

Complications of Prematurity 17.4%

Infections (CMV, meningitis, encephalitis, etc.)

13.8%

Other 26.6%

No determination of Etiology 12.8%

VISION IMPAIRMENT PARTICIPANTS

Low Vision (<20/200) 27.5% Legally Blind 28.4% Light perception only 6.4% Totally Blind 7.3% CVI 14.7% Dx of progressive loss 2.8% Variations of field loss 12.8%

In addition to a Dx of Deaf-Blindness:◦ 66.1% - complex health care needs◦ 56.9% - physical challenges◦ 53.2% - cognitive challenges◦ 22.0% - behavior challenges

Participants’ Age at Implant(Range = 6 months to 7 years 1 months)

12 months or younger = 1413 - 24 months = 3925 – 36 months = 2437 – 48 months = 5over 48 months = 10

(Participants ranged to 8 years of age at time they joined second study)

The children in the study are a very diverse group.

These children (as a group) do experience improvements in receptive and expressive language pre to post implant.

Individual outcomes vary considerably.

Data did NOT support the prediction of children’s progress on the basis of:

Severity of any additional disabilities, except cognitive challenges

Degree of visual impairment

OPTIMAL OUTCOMES seem to be associated with children who:

wear the implant(s) during all waking hours (and receive any necessary adaptations to enable this to occur)

have their implant(s) mapped frequently are positioned for best monitoring and access consistently receive communication services

for years following implant activation

Findings

Many participants did not have prelinguistic communication skills

Many participants did not have skills of functional object use

Auditory - verbal programs were not individualized

Many participants did not wear their implants consistently

Many participants were not mapped frequently (and, possibly, accurately)

Many children were “dropped” from auditory-verbal programs, due to lack of progress

Parents reported not being taught effective strategies that could be used at home

Frequent use (in therapy and in-home interactions) of toys / objects with “high” tactile and visual properties—but not sound

Many children do not have the opportunity to frequently hear speech directed to them in close proximity

Position oneself to best interact with the child in the specific routine

Speak close to the child’s processor Speak at regular volume Use speech that is repetitive Use speech that is rich in melody,

intonation, and rhythm

Use the acoustic “highlighting” technique—pause before saying the target word / phrase

(Estabrooks, 2001)

Monitor the rate of speech (provided to child)

Provide a number of repetitions in use of target word (e.g., “Listen! I have a cookie.” “Do you want to see the cookie? Let’s find the cookie.”

Minimize background noise

Definition: During an interaction with a child who has

received an implant, lead with speech! Implement visual, tactile, and / or

kinesthetic stimuli (i.e., touch cues, object cues, gestures, or signs) the child needs for support

Include spoken language directly in the interaction with the child, after other modality cues (Nussbaum, Scott, Waddy-Smith, & Koch, 2006)

Auditory SandwichAuditory Sandwich

Lead with speech! Say “Get your shoe…” (1-2 Times—NO MORE) WAIT for a response to this verbal cue (1 sec. - narrative description; 5-7 secs. - directives that require a response) Support with Tactile / Gestural Cue, while repeating the auditory “Get your shoe…” (1 time) WAIT, then say again and end with speech only, “You have

your shoe!”

Assist child if no response is made within 7 seconds

Step #1: Get your child’s attention by saying her name or by bringing her hand to your face so she can feel that you are talking.

Step #2: During daily routines speak to your child with your mouth close to the cochlear implant. Use single words and short phrases to talk about what she is hearing, seeing, touching, doing, and feeling. Talk about what is happening such as preparing food, getting dressed, or playing a game. Repeat words once or twice to make an “auditory impression.” Use the same words and phrases each time a specific routine takes place.

Step #1: Watch your child for little movements that may mean she likes or does not like something. Talk to her about what you think the movements mean. For example, if she moves her lips or smiles after you have given her a bite to eat, she may indicate that she likes the food. Say, “You want more!”

Step #2: : If your child has functional vision, watch your child’s eyes. Talk about what you think she is feeling or trying to tell you. For example if she appears to be looking at a rocking horse, say, “Oh, you want to bounce!” and put her on the rocking horse.

Step #3: If you and your child are playing with a toy and she begins to play with a different toy, follow her new interest rather than attempting to keep her focused on a specific toy.

Step #4: Watch your child’s facial expressions and imitate them. For example, if she makes a face while eating carrots, imitate her expression while shaking your head and say, “You don’t like carrots.”

Step #5: Watch your child’s gestures and talk about them (e.g., if she points at a light, imitate the gesture and say, “I see the light”).

Step #6: Listen to the sounds your child makes and imitate them as best as you can. Then wait for her make the sound again and imitate it once more. If she does not make the sound again, repeat the sound yourself. You can do this with lots of different sounds. You can also play games with the sounds, for example by making the sounds in a sing song voice.

Step #7: If your child says a word, repeat the word back to her and even add a word or two. For example, if she says “ba” and you think she means ball, say,“Ball. Let’s roll ball!”

KIDSDBCIhttp://www.kidsdbci.org/index.html

Teaching Prelinguistic Communicationhttp://www.nationaldb.org/documents/products/PM

TLargePrint.pdf