Amy McConkey Robbins
12 guiding premises of pediatric cochlear implant habilitation
Indiana University
almost 35 years since editor issue dr richard miyamoto introduced child would first pediatric cochlear implant ci patient dr miyamoto hired part coinvestigator team indiana university school medicine implanted many adults previous 5 years entering world pediatric cochlear implantation truly remarkable frontier first child implanted singlechannel house 3m device taught great deal electricallyevoked hearing could contribute development speech language literacy deaf child since time dr miyamoto combined experience working two thousand children cis one taught us something unique witnessed remarkable advances implant technology provision universal newborn hearing screening united states early fitting hearing technology traditional amplification cochlear implants babies difficult stand awe well children implants learning listen talk integrate neighborhood schools play musical instruments even become bilingual two spoken languages benefits however occur children receive excellent surgical placement devices welldesigned followup habilitation surgical insertion device enough dr miyamoto often reminded us team members work together provide program includes intensive listening spoken language habilitation rewards great article review twelve guiding premises form foundation habilitation prelingually deaf children cis1 premises amalgam research findings clinical experience broad range implanted children note much enhances learning children wearing cis consistent communication developmental children believe developmental approach needs taken fullest manifestation protracted period time children cis order enjoy high levels auditory spoken language literacy success 12 guiding principles presented three groups overarching goals learning environment content experience monitoring progress learn spoken language via ci two conditions must met first listener must sufficient necessarily perfect auditory access language code vowels consonants suprasegmental patterns make language put simply child must able hear language order learn think english speaker trying learn portuguese example taught soundproof window little chance anyone could learn portuguese way even child access sound patterns language second critical condition must also met sounds must gradually attached meaning attaching meaning sounds transmitted ci critical task whether postlingual child must remap new signal onto existing linguistic code child prelingual deafness must develop code de novo ci technology provide access habilitation parental followup nurturing auditory spoken language environment home school childs developing cognitive abilities create opportunities sounds become meaningful meaning established child unlikely demonstrate functional benefit cis addition older child receives cis intensive didactic habilitation need ensure sound becomes meaningful older children heard habilitation becomes rehabilitation communicative competence mean child understand utilize human communication level consistent age cognitive ability modes communication children hearing loss spectrum highly oral highly visual children cis learn rely heavily listening abilities others communicative competence include use sign language cued speech either fulltime academic settings receptive clarification assumption though parents sought cis value childs auditory spoken language skills intend devote energy improving parents encouraged select options child reflect values hold parents consistent goals childs future clinicians must develop practice skills within therapy room always greater goal skills generalize therapy room childs classroom home setting everyday environments parents primary agents childs communicative competence overall development learned research clinical experience believe clinicians effective view role largely one helping parents facilitate childs communication development day day within scope daily interactions family life older children whose parents school every day especially important convey message parents essential childs success sharing information home school great benefit involved accomplished variety ways including communication notebook travels home school back helpful parents complete interview childrens home inventory listening difficulties child reflects childs auditory behaviors home2 clinical experience suggests strong parental involvement sometimes negate effects weak educational setting whereas reverse far less likely clinicians often write habilitation plans isolate different domains communication writing separate goals child domains process break apart complex unified phenomenon communication artificially separate pieces challenge rehabilitation address goals way integrates reunifies pieces whole goal always achievable every rehabilitation session sometimes must practice help child overlearn particular skill traditional drill method unlike natural communication acceptable long clinician seeks put skill back purposeful communication soon child capable seek use fey termed hybrid approach intervention balancing structured practice naturalistic interactions3 due identification hearing loss babies via universal newborn hearing screening unhs united states countries growing number children hearing loss implanted infants toddlers increasing number clinicians serving population clinicians trained work babies provide services within model familycentered intervention intervention focuses parents family whole rather therapizing child ci moeller et al4 cite statistics dunst5 2 h per week perhaps spent therapy make 2 toddlers waking hours whereas everyday activities diapering feeding occur least 2000 times childs first birthday statistic convincing statement power families rather clinicians change agents childs communication cochlear implantation parents take advantage 10 interactions waking hour childs day provided 36000 teachable moments ages 1 2 years prior cis auditory development children profound hearing loss thought auditory training implication deaf children needed didactic instruction achieve hundreds listening skills make hierarchy auditory development professionals assumed child learned directly taught unreasonable assumption prior development multichannel cis given many profoundly deaf children hearing aids pattern perceivers able recognize patterns auditory information rather discriminate fine temporal spectral structure speech todays sophisticated technology cis provide potential deaf children utilize incidental learning unprecedented degree incidental spontaneous learning way children normal hearing nh acquire language theoretically efficient natural way learn native language still signal provided implant perfect representation even ci recipients using stateoftheart speech processing technology receive degraded auditory signal addition many children receive ci period auditory deprivation learned process information visually even improved auditory signal provided ci children may need systematic intensive training reach full auditory potential thus didactic instruction incidental learning advantages ci child general older child time cochlear implantation structured didactic instruction generally required rehabilitation goal diagnostic teaching approach identify child able adjust level difficulty tasks constantly challenging child evaluating conditions either enhance impede learning6 contrast traditional therapy approach goals set child session similar activities used underlying assumption traditional approach continued practice multiple sessions child increase accuracy skilla practice makes perfect philosophy approach reinforced way individualized education programs ieps usually written often using format johnny demonstrate x skill x number times using set x alternative responses x accuracy diagnostic teaching approach setting appropriate individual goals still critical clinician uses childs performance session determine needed next session child successful activity quiet conditions session child practices next session reach level automaticity activity made challenging following session clinician continually monitors factors favorable unfavorable childs learning focusing prominently positive aspect question things help child learn efficiently diagnostic teaching approach works well flexible creative clinician willing try new things knowing even particular technique successful child something valuable learnedthat use productive team classroom teacher sharing factors identified therapy useful challenging child classroom setting vice versa whenever possible advisable clinician use vocabulary concepts themes music classroom materials within habilitation activities serves reinforce targeted school situation example sevenyear old child cis may studying life cycle butterflies school within therapy may working recalling details passages child read benefits child therapist uses story activity shares theme butterflies approach provides student instructional time subject exposure related vocabulary concepts aids child recognizing connections ideas presented different settings also establishes reciprocity grounded respect ci clinician classroom teacher clinicians assure teachers goal make teachers job easier harder often build alliances regular education staff promote goodwill throughout childs years school alliances become important greater number children cis fully included regular education settings research observational reports indicate children cis seek appreciate music degree qualitatively different postlingually deafened adults cis7 8 clinical experience strongly supports use music integral component rather separate domain rehabilitation ci children multiple beneficial effects integrating music therapy session encouraging use home including articulation suprasegmental accuracy language development listening development social skills turntaking cultural assimilation9 goal habilitation babies wearing cis develop words auditory skills wetherby written communication develops infant caregiver sharing affective states joint attention intentions communicative abilities develop infancy form foundation emerging language10 clinicians see primary role guiding coaching parents key language teacher babys life research clinical findings documented auditory milestones achieved average child cis first year device use11 three different groups ci children reflect different preimplant characteristics show different patterns skill achievement child identified progressing slowerthanexpected rate red flags raised specific steps taken allowing clinicians intervene early possible identify source problem variety reasons important carry formal assessments children wearing cis12 however finelytuned analyses formal test results warranted interpretation tests test results may misleading virtually tests exception spontaneous language samples contrived measures language utilize formats picture pointing four pictured choices may bear little resemblance reallife communication demands children hearing loss often tested repeatedly thus may receive repeated practice artificial test formats may perform well structured tests repetitive nature therefore caution used children cis score within average range test instruments instruments may sensitive subtle higherlevel demands inference problemsolving topic shifts characterize realworld conversation13 wise augment use standardized tests informal procedures criterionbased evaluations importantly spontaneous language samples latter represent accurate window realworld communicative competence child wearing cis 12 premises exhaustive inventory factors important issues habilitation children cis rather represent authors opinion essential principles framework upon ci clinician may build effective program population premises based upon published research findings date upon authors clinical experience past third century working children using cis certain ongoing developments rapidlyexpanding field bring new information light allowing even effective habilitation offered children parents look onto frontiers technology clinical science cant help imagine astonishing innovations await horizon