Cochlear Implants

1. Cochlear Implants A Paradigm Shift for Children with Deaf-Blindness Kathleen Stremel The Teaching Research Institute Research supported by US Department of Education, H327A050079: Outcomes for Children Who are Deaf-Blind after Cochlear Implantation

2. OBJECTIVES • Objective 1.0 – The participants will gain knowledge to determine the content and strategies to individualize communication and language intervention for children who are deaf-blind with cochlear implants: WHAT TO TEACH • Objective 2.0 – The participants will gain knowledge of the strategies and procedures to use auditory and speech systems to improve child outcomes across environmental sounds, speech perception and comprehension, and language development.

3. Potential Outcomes for Children Who Are Deaf-Blind with Cochlear Implants

4. Auditory Brain Development • The research for auditory brain development should guide the way we teach children to listen and to use auditory input • We hear with our brains, not our ears • A child’s brain must be accessed and stimulated to develop (Carol Flexer) • Acoustic accessibility of intelligible speech is essential for brain growth • We are either “growing” the brain or we are not.

5. Children Who Are Deaf-Blind with Cochlear Implants • Children with CHARGE – 10 children • Children with Auditory Neuropathy – 9 children • Children born prematurely - 27 children • Children with meningitis – 3 children

6. Vision Information on Children Who Are Deaf-Blind with Cochlear Implants • Low vision – 10 % • Legally blind – 28% • Light Perception/Totally blind – 26% • Cortical Vision Impairment – 22%

7. Additional Disabilities • Physical Disabilities – 63.8 (mild to severe) • Cognitive Disabilities – 67.5 (mild to severe) • Behavior Disorder – 35.7 (mild to moderate) • Complex Health Care Needs – 70.0 (mild to severe)

8. Ethnicity • White - 70.9% • Latino – 12.7% • African American – 10.9% • Other – 5.4%

9. Age of Implant

10. Cochlear Implants: 20% Hardware & 80% Software • We see tremendous variability in the outcomes for children who are deaf-blind • Children must wear their implants all waking hours • Children must receive frequent mappings • Intervention must have a focus on family-child interactions with the interventionist as coach

11. Variability in Outcomes • Suggests the need to individualize and adapt approaches • A number of children with deaf-blindness receiving implants do not have prelinguistic skills. • The child’s early communication skills, auditory and speech perception, speech development and language development must be assessed so that the program can be individualized • Even though a child may receive diagnostic therapy, they need to learn within the natural learning environment as other skills are being developed • What do we want as outcomes…are we willing to do what it takes

12. Facts • Many of these children do not receive intervention or therapy specific to cochlear implants… • The variability in outcomes indicates the need for individualized and adaptive approaches across receptive and expressive language (Nussbaum, Scott, Waddy-Smith & Koch, 2006) as in the approach: A…..AV…..AV…..VA…..V the A to V continuum • Children who are deaf-blind may need more than an Auditory to Verbal continuum, as their expressive language may not be visual sign language, but may be gestural, pictorial, or a different augmentative system.

13. Instructional Intensity • Often we see family members and service providers using the same strategies after the child was implanted as before… • If we are to impact the brain, we have to change the way we provide intervention • We need to individualize the program for the child’s communication, receptive and expressive language system • Our intervention should teach parents how to interact with their child • Whereas the child may benefit from intensive therapy, the child must also learn to listen in the home and classroom in ongoing activities.

14. What Are We Teaching • Prelinguistic communication is a necessary, but not sufficient condition for auditory development • Differing responses to familiar speech • Differing responses to environmental sounds • Differing responses to music • Differing responses to speech • Use of vocalizations as communication • Differing levels of vocal imitation • Use of speech to communicate • Use of intelligible speech

15. Developmental Stages • Detection • Discrimination • Identification • Comprehension

16. Inventory for Environmental Sounds in the Home • See Attachment B for Inventory for Sounds in the Home & Community

17. Sample of Inventory

18. Training focused on Developmental Progression

19. Environmental Sounds Motivational Objects Sounds associated with favorite activities Favorite toys – use sound Familiar Voices General awareness Mother’s voice Responding to name Responding to expressions Detection – We must teach the child to detect sounds –

20. Communication Criterion Referenced Assessment • See Attachment C for Communication Criterion Referenced Assessment

21. Communication Criterion Reference Assessment

22. How Do We Teach? • Establishing a listening environment • Coaching families • Using Auditory-Verbal techniques • Using natural routines and activities to embed opportunities for listening and communicating

23. Establishing a Listening Environment • Position oneself to best interact with the child in the specific routine • Speak close to the child’s microphone • Speak at regular volume • Minimize background noise • Use speech that is repetitive • Use speech that is rich in melody, intonation and rhythm • Use Acoustic “highlighting” techniques (Estabrooks, 2001)

24. Using Auditory-Verbal TechniquesA…….Av…….AV…..AV……..V • Repeating back to the child what he vocalizes • Using a hand cue for listening (45° slant) • Leading with the Auditory • Putting spoken language directly back into the interaction after visual, tactile or kinesthetic cues • Waiting or pausing for responses from the child • Goals include the integration of auditory, language, cognition and speech within normal development • All-day listening environments are created for the child within meaningful contexts of activities

25. Where Do We Teach? • 95% of what a child learns in life is learned at home. (Armstrong, 1991), • Parents are the teachers, not the therapists

26. Paradigm for Learning 3 Prong Contingency: Antecedent – Behavior – Contingency • Antecedents Quiet environment FM System in class Lead with Speech Support with appropriate support for child with Speech Touch cue Object cue Gesture cue • Behavior • Consequence Maximum reinforcement for response to Speech Repeat speech to confirm or expand

27. Using the A-B-C’s to implement your child’s program: Antecedent-Behavior-Consequence • Antecedents - Antecedents include adaptations to the visual, auditory, and positioning aspects of the physical environment. • Antecedents also include the level of support that you need to provide for your child to be successful. • The natural occurring steps in a routine or activity serve as a powerful antecedent. • All aspects of the antecedent should be considered for the individual your child in terms of: o visual field o reduction of glare o special lighting o amplification o reduced background noise o positioning for optimal responding o supports or prompts • The antecedent conditions should increase the probability that the targeted behavior occurs. • The antecedent conditions should be a natural part of the activity if possible. • The supports or prompts should be gradually faded.

28. Auditory Sandwich • Critical : • 1. Lead with speech! Wait and Support with Visual/Tactile. • 2. Use an “Auditory Sandwich”…lead with speech, support with a prompt, end with speech. Example: (a) Say, “ Get your bib”…….(b) Wait for a response to your verbal…(c) Say, “Get your bib” while pointing, (d) end, “You have your bib!”

29. Behaviors: • The communication behavior being targeted will include a combination of: 1. A Form 2. A specific Communication Intent 3. A limited number of Content items. • Break the behavior down into small sequential steps if your child is not successful. • Teach a new form to a communicative intent that your child already uses.... New form-Old Communicative Intent. • Or, teach a new communicative intent to a form that your child. already uses.... Old form-New Communicative Intent. • The specific form being targeted may need to be “shaped” into the final, targeted form. • Your child may need supportive accommodations. • Determine the “appropriate” time-delay for each individual child.

30. Consequences • The consequence should be directly related to the antecedent and the behavior. • Different potential motivators should be continuously assessed to avoid satiation. • Generalized consequences may need to be considered for older child’s. • The consequences for challenging behaviors need to be assessed to determine the function the behavior is serving.

31. Other Activities to Encourage Parents To Do • Maintain a joint focus on objects and activities • Play ritualized games with younger children • Sing and read nursery rhymes • Name objects in the environment • Describe the location of objects • Read to your child • Play music and instruments

32. References • Barnes, J. M., Franz, D., & Bruce, W. (1994). Pediatric cochlear implants: An overview of alternatives in education and rehabilitation. Washington, D.C.: Alexander Graham Bell. • Cole, E. B. & Flexer, C. (2007). Children with hearing loss: Developing listening and talking. San Diego, CA: Plural Publishing. • Estabrooks, W. (2001). 50 frequently asked questions about auditory-verbal therapy. Toronto, Canada: Learning to Listen Foundation. • Nussbaum, D., Scott, S., Waddy-Smith, B., Koch, M. (April, 2006). Spoken language and sign” Optimizing learning for children with cochlear implants. Paper presented at Laurent Clerc National Deaf Education Center, Washington, DC. • Taylor, E., Stremel, K., & Bashinski, S. (2008). Cochlear implants for children with combined hearing and vision loss. OSEP grant: #H327A050079.