Cochlear Implant Program | Children's Program

Whether or not to get a cochlear implant is a big decision. It is an even greater responsiblity when you are making the decision for someone you love. Children undergo a complete interdisciplinary evaluation before receiving a cochlear implant at the University of Michigan. The information developed from this evaluation helps the team and the parents make the best decision for the child. Of course, if the child is old enough, he or she is an important part of the decision making process.

The time period needed to complete the necessary evaluations varies greatly between individual children. Before a surgery date can be scheduled, reliable unaided thresholds and aided thresholds for each ear and in a binaural condition must be obtained. This may take only a few visits for some children, but for other children it may take many more. We work with each family to coordinate appointments as much as possible to minimize the number of trips to our center.

The cochlear implant team will work with all families to discuss financial issues involved with the children's implant program. Surgery is not scheduled until insurance approval is obtained, which may take from 6 to 8 weeks after the initial visit. Families are encouraged to take advantage of Children's Special Health Care Services through the Michigan Department of Community Health if neccessary.

A. Audiological Evaluation/Hearing Aid Evaluation
The audiological evaluation begins with a standard audiogram to confirm the child's hearing loss . Auditory Brainstem Response (ABR) testing and Otoacoustic Emissions (OAE) testing are completed as required. Testing is also completed while the child utilizes his/her personal amplification (typically hearing aids) to determine how loud sounds must be before the child can detect the presence of sound. This testing is completed in monaural (one ear) and binaural (two ears) conditions.

B. Medical Evaluation
During the medical evaluation, the patient and family meet with an otologist/neurotologist to discuss surgical considerations, and a complete medical history and physical examination are performed. The surgeon attempts to identify the cause of the hearing loss and may consider alternative treatment options.

C. CT Scan
If the audiological and medical evaluations indicate that the child is a candidate for a cochlear implant, a computed tomography (CT scan) of the temporal bone is obtained. This is an imaging study that provides an image of the structure of the cochlea and identifies any abnormalities. Severe abnormalities may present surgical challenges, but do not necessarily preclude the patient from implantation.

D. Speech Perception Testing
Speech perception testing is completed to assess the child's ability to understand speech in an auditory only condition with the assistance of amplification. The specific battery of tests used depends upon a variety of factors, such as age and language level of the child. These tests are used to determine how much benefit the child receives from hearing aids.

E. Speech and Language Evaluation
The purpose of the initial speech and language evaluation is to determine if the child has developmental language and/or articulation disorders, to describe the child's communicative status with respect to normal language development and to help define expectations for speech and language skills. This evaluation provides an opportunity to develop preliminary goals, objectives and treatment approaches. The specific test materials used in the evaluation are based on the child's age and language level.

F. Psychological Evaluation
The psychological evaluation is completed to assess the child's cognitive abilities and to rule out factors other than hearing impairment which may be inhibiting the child's auditory development, such as a learning disorder. The psychologist may recommend that the child be seen by other professionals for additional testing. This evaluation will be completed as needed.

G. Electric Auditory Brainstem Response (EABR)
This test is usually performed on the day of surgery under general antestesia. It involves the delivery of electric stimulation near the inner ear and the recording of responses from the hearing nerve and brain. The purpose is to select the ear that responds best to electrical stimulation.

H. Other Tests
If the child has a history of balance problems, a Basic Balance Function Test (BBFT) may also be recommended. Neurological or ophthalmological evaluations may also be completed.

The activation is an exciting and exhausting day for the child, as well as the family. We try to create an atmosphere that is friendly and relaxing to the child and conducive to the intense listening required during the programming of the speech processor. The University of Michigan Cochlear Implant Center has video monitoring and taping capability which allows family members and other visitors (e.g. relatives, school professionals, therapists) the opportunity to view and/or record the activation without distracting the child. We extend invitations to the educational professionals and school therapists involved in the management of the cochlear implant recipient's case, to attend the activation and/or any other follow-up appointments. We ask that they obtain permission from the parents to attend and let us know that they will be coming to a given appointment.

B. Audiological Monitoring
Maintenence and monitoring of a child's map and audiological skills is essential for optimal device use. Following the initial activation of the cochlear implant, a child will typically be seen every 2 weeks for a 2-hour appointment for reprogramming of the device for the first couple of months. Implant threshold and comfort levels frequently change during these first few months as the auditory system experiences electrical stimulation and learns how to interpret this information.

C. Speech Perception Evaluations
A child's listening skills also become more sophisticated as he/she learns to listen with the cochlear implant and with repeated exposure to the test environment. Interval evaluations of speech perception abilities are completed in conjunction with speech and language assessments to ensure proper device functioning and monitor a child's performance. These tests are completed annually and are very important to monitor both a child's performance and the functioning of the device.

Aural (Re)habilitation and Speech Services

Any child receving a cochlear implant will require rehabilitation in order to maximize their listening potential. Patients of the University of Michigan Cochlear Implant Program are enrolled in different therapy options to meet their needs. These options are described in detail below:

A. Short Term Auditory Therapy (STAT)
To take advantage of the frequent trips to the center for programming sessions during the first 6 months, the child may attend STAT (Short Term Auditory Therapy) with one of our speech-language pathologists. The goal of this therapy is to provide the parent with information about rehabilitation and how to focus on auditory goals in daily life. During these sessions, the parents are active participants in the therapy goals and they learn how to encourage listening in everyday situations.

B. Auditory-Verbal Therapy (AVT)
For young children who receive cochlear implants at an early age, the program's recommendation is to enroll in Auditory-Verbal Therapy to maximize the child's benefit with their cochlear implant. Parents are given this option and may choose to enroll if desired. Both speech pathologists on staff are trained in utlizing the Auditory-Verbal approach.

C. Customized Therapy Options
The speech pathologists and parents may coordinate other therapy options as they are needed. These may include auditory therapy for older children who use sign language, therapy for previous non-users of cochlear implants, assistance transitioning from manual to oral communication options, or traditional speech therapy services for children with expressive communciation difficulties.

D. Evaluations
Progress is measured through interval evaluations with the speech-language pathologist and audiologist once a year. During these evaluations, a child's speech recognition abilities, speech intelligibility, and language abilities are reassessed formally through the administration of various speech perception and speech-language measures. The reassessment of a child's skills occurs after the firs 6 months, and annually thereafter. The purpose of these evaluations is to monitor a child's performance over time and provide the family and educational staff with recommendations. Monitoring is also essential in order to ensure device functioning and provide the audiologist with feedback regarding possible audiological needs.

Auditory-Verbal Therapy

What is “Auditory-Verbal Therapy?”
The goal of the Auditory-Verbal practice is that children with hearing impairment can grow up in a regular learning and living environment that enables them to become independent, participating, and contributing citizens in mainstream society (Auditory-Verbal International, Inc., 1991). Auditory-Verbal therapy teaches parents how to create an auditory learning environment for their child to develop spoken language through listening during everyday natural and meaningful communication.

Auditory-Verbal Therapy is designed for the parents to participate in the child’s education. Therapy is diagnostic, with each session being an ongoing evaluation of the child’s and parent’s progress. The children learn to use their amplified hearing or their cochlear implant to listen to their own voices, the voices of others, and the sounds of their environment in order to understand spoken language. There is no set curricula per se, rather, Auditory-Verbal Therapy encourages and follows natural language and speech development. The parents and therapist encourage the child to integrate hearing, language and spontaneous speech into the child’s personality (Pollack, 1985; Estabrooks & Samson, 1992; Estabrooks, 2001). While certain language curricula might be employed, these materials are designed for children with normal hearing abilities.

The Auditory-Verbal Approach differs from the auditory-oral approach and traditional aural habilitation in that families who choose the AV approach follow a set of guiding principles to enable their child who is deaf to learn to listen and process spoken language (see principles below). Although families who participate in oral education programs or auditory-oral programs may utilize strategies and techniques of the AV approach in their practice, an Auditory-Verbal intervention program embraces all the guiding principles. The salient differences may be that traditional aural habilitation programs and auditory-oral programs may rely on therapists and teachers as models and children who are deaf and hard-of-hearing may receive instruction or therapy in groups. There are no “Auditory-Verbal” schools, in that the purpose of integration is to educate the child in the Least Restrictive Environment (LRE) with the highest expectations, and the mainstream classroom serves as the LRE for children who are deaf/hard-of-hearing.

Doreen Pollack, one of the original founders of the Auditory-Verbal approach, stated that the goal of the approach is that children who are deaf and hard-of-hearing are integrated into their community, and a typical living and learning environment is retained. She believed that everyone in this environment must believe that the child can hear, expect the child to respond appropriately, and show him or her how to communicate through spoken interactions. When an all-day listening atmosphere is created for the child, surrounded by meaningful contexts of daily activities, with children who have normal hearing and language abilities, communication becomes relevant.

Please refer to 50 FAQs About AVT 50 Frequently Asked Questions about Auditory-Verbal Therapy Edited by Warren Estabrooks, (2001), available from Auditory-Verbal International, Inc. for more information.

Additional sources:

The Volta Review, Vo. 95, No. 3, Summer 1993,: Goldberg, D. Auditory-Verbal Philosophy: A tutorial

Estabrooks, W. (1994). Auditory-Verbal Therapy for Parents and Professionals

Robertson, L. (2000). Literacy Learning for Children who are Deaf or Hard of Hearing.

PRINCIPLES OF AUDITORY-VERBAL PRACTICE
• To detect hearing impairment as early as possible through screening programs, ideally in the newborn nursery and throughout childhood.

• To pursue prompt and vigorous medical and audiologic management, including selection, modification and maintenance of appropriate hearing aids, a cochlear implant, or other sensory aids.

• To guide, counsel, and support parents and caregivers as the primary models for spoken language through listening and to help them understand the impact of deafness and impaired hearing on the entire family.

• To help children integrate listening into their development of communication and social skills.

• To support children’s auditory-verbal development through one-to-one teaching.

• To help children monitor their own voices and the voices of others in order to enhance the intelligibility of their spoken language.

• To use developmental patterns of listening, language, speech, and cognition to stimulate natural communication.

• To continuously assess and evaluate children’s development in the above areas and, through diagnostic intervention, modify the program when needed.

• To provide support services to facilitate children’s educational and social inclusion in regular education classes.

Adapted from: Estabrooks, Warren, “Auditory-Verbal Therapy: Talking Through Listening,” The Listener, June 1998.

Why Auditory-Verbal Therapy?
The staff and faculty of University of Michigan Cochlear Implant Program believe in and strive to provide families with knowledge of the Auditory-Verbal approach for teaching their child with a cochlear implant to be successful using spoken language. These beliefs are based on findings that children using an Auditory-Verbal approach typically grow up in regular mainstream environments, and likewise work in such environments as adults (Goldberg, D.M. and Flexer, C., 1993;). In this approach, families of all backgrounds and social situations can teach their children who are deaf to use spoken language without learning a new language themselves (such as sign language). Since 90 % of children who are hearing impaired are born to parents who have normal hearing,(Lynas, Hungtington, and Tucker, 1988), learning a new language presents an additional challenge. Likewise, the use of this approach has proven to be effective in literacy development (Robertson. L. and Flexer, C. (1993); Roberts, S.B. and Rickards, R.W. (1994). The speech-language pathologists and audiologists at our Program have sought to apply principles of typical speech, language, and auditory development into our counseling, presentations, and research. Please refer to www.beginningssvcs.com for additional information.

Sources
Roberts, S.B. and Rickards, R.W. (1994). A survey of graduates of an Australian integrated auditory-oral preschool. Part 1: Amplification usage, communication practices and speech intelligibility. The Volta Review, 96, 185-205.

Goldberg, D.M. and Flexer, C., 1993;Outcome survey of auditory-verbal graduates: a study of clinical efficacy. Journal of the American Academy of Audiology, 4, 189-200.

Robertson. L. and Flexer, C. (1993);. Reading development: a parent survey of children with hearing-impairment who developed speech and language through the auditory-verbal method. The Volta Review, 95, 253-261.

What about sign language?
The University of Michigan Cochlear Implant Program recognizes and feels strongly that no one approach is right for everyone. Auditory-Verbal Therapy will not be right for every family. Many families have been successful in using various forms of sign language. If the family’s informed decision is to select an option that includes sign language, they should be willing to learn the language fluently in order to maximize the child’s success with the option. In addition, children with additional disabilities (e.g. autism, PDD, Down’s syndrome) who receive cochlear implants may utilize sign language quite effectively, as spoken language may not be the primary expectation for receiving a cochlear implant. Auditory-Verbal strategies may still be employed with children who use sign language in order to teach listening skills, in addition to incorporating visual, tactile, and/or kinesthetic information.

When a family who chooses to get a cochlear implant for their child incorporates sign language into their child's educational program, expectations may be different for what the child will achieve through listening alone. When sign language is used in conjunction with speech, the auditory and visual channels are sharing input, and typically the visual channel is how the child has learned most things prior to the cochlear implant. Moreover, it is important to realize the variety of sign language available, and the difference between American Sign Language (ASL), (which is an entirely different language using different sentence structure than spoken English), and Signed Exact English (SEE), and variations of SEE. See www.gallaudet.edu or www.masterstech.com for additional information.

Preoperative Assessment: Children

Post-operative Audiological Protocol