A Retrospective Look at Cochlear Implantation in Older Children with Prelingual Hearing Loss
Part 2: Experiences of Older Deaf Children Using Hearing Aids
In the mid 1990s, parents of older deaf children observed the benefits of cochlear implants for young children. Many deaf children were using hearing aids with minimal benefit and were struggling, sometimes in mainstream classrooms. The negative impact of the child’s hearing loss on academic progress became more evident as the children moved into upper grades.
Parents recognized that communication and educational support typically decline as children get older—despite the fact that academic and social activities become more challenging. Though their children were not the ideal age for cochlear implantation, parents felt that their children deserved the opportunity to try new technology that could enhance communication and quality of life. The children themselves typically shared their parents' dreams. Many were integrated into mainstream school settings and experienced their hearing loss as a significant disability that CI could potentially mitigate, at least partially. Many CI teams, however, had concerns about making the intervention available to this population. It was clear that in order to achieve maximum benefit, older implanted children would need to be enrolled in intensive auditory rehabilitation programs designed to address their unique needs.
What have we learned from these later implanted pediatric recipients?
We learned that the speech perception skills of someone who is prelingually deaf and later implanted is a key indicator of expected auditory skills post CI. We also confirmed the effect of age at the time of CI as a key parameter in other auditory outcomes. Children who were implanted at a later age differed significantly from children who were implanted at an early age in various aspects including the course of the rehabilitation process, the pace of progress, and the eventual outcomes.
We also learned that later implantation can facilitate progress in communication skills. Over time, many of these older children experienced significant improvement in their communication function. Some gradually changed their communication habits from using primarily visually based communication with little meaningful auditory information to an auditory supported method of communication. Long term outcomes included enhanced speech reading including understanding speech without visual clues in certain situations, better speech intelligibility, music appreciation, increased ability to understand speech on the telephone, and improved perception of environmental sounds. Parents reported that their children were more self-confident in various social situations and functioned more easily in their regular classrooms.
Interest Increased from Families
Due to the positive impact of later implantation for mainstreamed children, we saw an increase in interest in CI from this population. Typically, candidates were children and adolescents who attended special classes for children with hearing loss. Many students communicated using sign language—either sign alone or total communication. Many had significant spoken language delays of 4 years or more and some had disabilities in addition to their hearing loss.
This new group of candidates challenged CI teams in many ways. Not only were they thought to be "too old" to benefit from CI, their oral language skills were often poor. There were questions regarding their ability to enhance their auditory abilities when their communication mode was not based upon listening and spoken language. There were also concerns regarding whether they would be sufficiently motivated to complete the needed intensive rehabilitation that would likely take many months, or even years.
The decision on whether a child was an appropriate CI candidate was even more complicated in instances in which there were additional disabilities. If candidacy was approved for a child with additional disabilities, it was critical that the family had realistic expectations regarding likely outcomes and the need for a unique course of follow-up rehabilitation. Clinicians and family members together needed to collaborate to build realistic rehabilitation goals. We also needed to gain the support of the child’s educational team and ensure that the classroom environment would be supportive.
In the program where I worked in Israel, we initiated efforts at the national level with the Ministry of Education to increase the educational support and rehabilitation resources provided to students with cochlear implants. We communicated and coordinated with school staff to establish a collaborative process during the candidacy evaluation stage and throughout the rehabilitation process. We visited schools to meet not only with educators, but also with a child’s classmates. We adopted an approach of acceptance and respect for the use of sign language. The message conveyed by the CI team regarding use of sign language by candidates and their parents was that CI does not exclude the use of sign language. For these later implanted children, it was important to encourage the children's continued use and further development of sign language skills. Accordingly, professionals from the CI team used signed Hebrew along with spoken language (total communication) with these candidates and CI users.
What insights have we gained from these later implanted children?
We learned that the amount of auditory language that an older candidate already has in place, as well as the frequency of using such language, is a factor in determining CI outcomes. Motivation is a highly influential variable regarding participation in CI rehabilitation. The CI recipient's cooperation with the rehabilitation demands and their willingness to take on proper maintenance of the CI cannot be taken for granted with older children or adolescents. Given the later age, cochlear implantation may conflict with their identity relating to hearing loss; such conflicts must evaluated to determine an appropriate path forward. Teenagers must address which community they identify with and whether a CI will present identity concerns. Do they identify as having hearing loss, being part of the Deaf community, or being part of a new paradigm allowing them to be deaf but functioning within the hearing world with CI?
Auditory rehabilitation is essential for progress; a lack of consistency in their auditory training program can interfere with progress. We also learned that collaboration between the CI team and the educational team is critical to the progress of the older child or teenage cochlear implant user.
Beyond all of the complexities and challenges, we learned that CI provides significant benefits for this group of candidates!
Important Benefits in Older Children Changed Minds
Implanted teens and children with the above age and communication characteristics were able to identify many environmental sounds and their awareness of auditory stimuli in their environment improved significantly. They reported meaningful enhancements to speech reading. In many cases, following intensive long-term auditory training, they were able to understand simple sentences without speech reading. This ability was usually restricted to quiet conditions, certain speakers, and short sentences on an identified topic. However, this was a groundbreaking experience related to auditory comprehension. Some of older recipients were able to reply to simple questions and react spontaneously to greetings in everyday situations. Some even managed to talk on the phone with their parents, usually when the conversations were relatively structured and on specified topics. Most of these recipients used their device regularly and were positive regarding their decision to pursue a cochlear implant.
With these insights, CI clinics began to open up their programs to this new population of older children and adults. This required a new approach for follow-up rehabilitation, which will be addressed in future posts.
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