In many cases, it is months after learning about the existence of an implantation before the child is declared a candidate for a CI. The decision point for our experience came after taking our son for a cat scan. In that it was confirmed that he had all the necessary anatomical components to make the cochlear implant work. At this point, we had about one week to decide a trajectory path for our son’s lifetime. All the research leads up to this single moment. The factors that were included in this decision came down to a number of items, which were researched and agonized over for months. The first decision we had to make was do the implantation itself. No surgery comes without a level of risk. The variables are too many considered, but implantation surgery is not an easy elective procedure. It takes great skill on the part of the surgeon and great trust of the parent to release their child into the care of these health professionals. There are many reasons why my wife and I chose implantation, but the single most important factor to us, and many, is life opportunities.
After many conversations and much reading the decision was made to have our son implanted. The first point that we considered was his long-term outcome as a fully deaf person. He could have a rich, full life without implants. We had come to see that he did not have a disability, that he was a bright, intelligent child that had limitless potential. But, in our estimation, being fully deaf did not give him the maximum opportunities in life given he was a candidate for implantation. This is a common theme amongst parents. When asked to give three reasons why they implanted their child, the top reason came back to providing the maximum opportunity to the child. In the majority of those interviewed, the primary means they saw to providing maximum opportunities to their child was through hearing and speech. Steve stated he wanted to “give him the absolute best chance to succeed in today’s world” and Betty stated, “this is not a world made for non hearing.” Many believed that the benefits far out weighted the risks. The decision was based on the fact that the risks of surgery and failure of the technology was far less than the potential gains for him throughout his life. As Nancy states,
“I wanted her life to be as close to the same as any typical school. Secondly I did not want to have her to rely on someone to translate what was being said to her of what she was signing back, I couldn’t imagine [having] the type of dependency. I couldn’t imagine my own life without sound and how successful prior children with implants were”
Once the decision was made to go with implantation, the second decision points came forward; one or two ears. In many cases, parents have no choice in bilateral versus unilateral CIs. The decision to implant a single CI or bilateral CI goes far beyond the risk presented during the procedure. We struggled with this decision as much as we struggled with the decision to implant. At the time, the prevailing literature and wisdom on the subject was to implant a single ear and save the other for future development. Its important to note that implantation destroys any “natural” hearing.
We made the decision to pursue bilateral implantation based on two decision points. First, implanting in a single ear relegates the pre-lingual implanted child to a different set of issues experienced by those with unilateral hearing loss. This justification is a common one for those parents making the decision to bilaterally implant. As Mary states,
“The research we reviewed 9 years ago suggested that performance in the classroom and in acoustically unfavorable environments absolutely was not as good as with two CIs. Understanding (a tiny bit about) how the brain plasticity works, what we learned suggested that maximizing those pathways, through, as much sound as possible, was the way to go to maximize performance.
Also, though we did and do understand (and appreciate!) that research is ongoing in terms of future medical advancements, they were not close enough in time to make it seem like a reasonable approach to wait for them. In short, we wanted to do the best we could for Will with what was available then. Undoubtedly that might mean he would not be afforded the option of some future advancement, but it seemed more sensible to us to be practical and realistic in working with what we had. If there was more concrete information available about what was coming, and if it was coming soon, perhaps our decision would have been different.”
Researching this decision point the implantation of a single CI does present the student with significant benefits and access to sound for language development. But, does it can be said the idea of hearing through one ear solve the problem for a hard-of-hearing student medically, but what about academically. For a moment, let’s remove the idea of cochlear implants from the stage. What do we know about student with unilateral hearing loss as compared to their normal hearing peers?
In addition to the information about unilateral hearing loss, as a technologist I considered the implications of the processors. The processors, the exterior portion of the implant, contain a microprocessor for sound. The version of implant that our son would receive is the equivalent of a 24-channel stereo in his head. The implant delivers the sound, but the processor is the engine that drives the care. If you put a cochlear implant’s sound processor in a typical technology curve, you can expect that the device will get smaller, faster and cheaper over time. As we move into the future, as technology gets smaller, faster, cheaper, the processor’s ability to acquire and interpret sound will drastically improve. Technological advances move significantly faster than medical advances, so the waiting for an advancement in medicine with an unplanted ear seemed a higher risk than implanting both ears and relying on the technology paradigm curve.
A substantial body of research has demonstrated that pre-lingual hard-of-hearing children are able to develop significant speech production skills through the use of a single CI [1-5]. For example, some of the advantages observed in a case study of a single CI user included an increase in speech and eligibility, an increased receptor vocabulary, a decrease in production of nonwords, and increased response to questions . Many studies have indicated a direct positive correlation between language acquisition and age at implantation with plateaus after a “sensitive” period that ends at about age eight [7-10]. The current literature points to the early implantation of individuals to maximize this “sensitive” period .
Given these successes, there is a movement toward bilateral implantation. The use of bilateral CIs allows the implant user to more closely mimic normal hearing, but as many practitioners will point out, its not normal hearing. A review of the literature on BCIs has shown advantages for many individuals in the areas of improve speech recognition, sound localization, and reduced head shadowing effect [12, 13]. Other study has suggested that children who have been bilaterally implanted are better at expressive language, reading skills, and linguistic competency . Measures of speech perception, intelligibility, knowledge acquisition, working memory, and others have been significantly investigated in recent years, but little is known about these children’s ability to function within a complex auditory environment [12, 13]. Many speech therapist and audiologist will argue that a visual approach to language acquisition is that hearing has been found to be the best modality for teaching speech, reading, vocabulary and cognitive skills [14-16]. Compounding the problem is the fact that most hard-of-hearing children traditionally begin an intensive ASL regiment once identified as hard-of-hearing. Given that ASL has no relationship to spoken English , the literature reveals that those individuals who are born with profound hearing loss typically, even with the assistance of visual languages, graduate high school with a fourth-grade English reading level [18, 19].
Regardless of the path one chooses for their child, the path is not an easy one. Hearing loss in a child for hearing parents presents a significant natural language barrier . With very few hearing parents being visual language competent, the vast majority of hearing parents instinctively try to teach their children language via the spoken word [21-24]. Given that much of our language learning happens from age one through eight , it is easy to understand why pre-lingual hard-of-hearing children have a hard time learning language.
Post implantation in an adolescent has presented a number of issues. Children with unilateral hearing loss are at 10 times greater risk for academic failure that children with normal hearing in both ears [25, 26]. Specifically, students who experience a degree of UHL are at a higher risk for educational, speech–language, and social–emotional difficulties than that of their normal hearing (NH) peers [27, 28]. UHL contributes to a significant risk for reading difficulties and as previously stated. Some studies have shown that high school graduates with hearing loss fall between the fourth and fifth grade reading level [19, 29, 30]. Given this relationship between unilateral hearing loss and academic performance, it stands to reason the assessment standards for UCI recipients should be measure against peers with the same condition. The research shows that children with a UCI can do well with obtaining access to speech and sound, but can still be at a disadvantage academically. We know that even individuals with dual CI do not have the same access to sound as an individual with no hearing loss. A 2008 study found that late implant recipients were able to convert from visual based language to the use of oral language with a higher degree of success for those who’s primary language was cued speech versus ASL . There is a growing body of evidence that individuals with pre-linguistic deafness can achieve language understanding through the use of cochlear implants [31-33].
Currently, an option of care for profoundly hard-of-hearing individuals that qualify has been a unilateral CI (UCI), the implantation of one ear only saving the other ear for future medical advancements. A substantial body of research has demonstrated that pre-lingual hard-of-hearing children are able to develop significant speech production skills through the use of a single CI [1-5] For example, some of the advantages observed in a case study of a single CI included an increase in speech and eligibility, an increased receptor vocabulary, a decrease in production of non-words, and increased response to questions .
Although the advantages of a UCI greatly increase the ability of the student to obtain speech, the risks associated with unilateral hearing loss (UHL), either natural or through the use of a UCI, have been well documented in the literature. Specifically, students who experience a degree of UHL are at a higher risk for educational, speech–language, and social–emotional difficulties than that of their normal hearing (NH) peers [25, 28, 34]. UHL contributes to a significant risk for reading difficulties and as previously stated, studies have shown that high school graduates with hearing loss fall between the fourth and fifth grade reading level [19, 29, 30].
Peters noted in the article, Rational for Bilateral Cochlear Implants, that children experiencing UHL are 10 times more likely to fail a grade or need additional educational resource assistance and are twice as likely to exhibit behavior difficulties in the classroom . The case for bilateral cochlear implants has been made based on the concept of normal hearing that is binaural. In recent years the number of cochlear implants bilaterally implanted into children have significantly increased. As of October 2005, according to the review of three major implant manufacturers, there are approximately 2803 bilaterally implanted individuals worldwide. Approximately, 58% or 1402, of these implanted individuals are children. The used of binaural CIs allow the implant user to more closely mimic normal hearing. The normal hearing brain uses rapid, real-time analysis of signals from two ears combined with data to hear. A review of the limited literature on BCIs has shown advantages for many individuals in the areas of improve speech recognition, sound localization, and reduced head shadowing effect [12, 13].
Regardless of one’s view on deafness, the condition presents a significant barrier for those affected. There are many different educational routes, but none with a clear path for success. For instance, now, with a cochlear implants, many deaf students are enjoying a new world of sound. Cochlear implants are transforming how language is taught for some deaf children, but a cochlear implant is not a cure for deafness and not every deaf person is a candidate for a cochlear implant. The implant is nothing more than a tool that allows deaf children to acquire access to sound and results vary based on many different factors. Learning to utilize the technology requires a significant amount of work on the part of parents, therapists, educators and the student and the educational approach can affect the results.
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