Cochlear%20Implants

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
IF We want children to THEN
Listen and learn They need to consistently wear their implant
Listen to your voice as well as their own voice They need to have consistent, early mappings
Listen to environmental sounds These sounds need to be contingencies
Begin to understand spoken words and phrases We need to teach them how
Integrate listening into the development of communication We need to lead with speech and support the child with other modalities
Comprehend speech within the context of their natural environments We need to teach within the context of the natural environment motivational activities
Communicate with others in the context of their natural environments We need to build upon the communication systems that they are already using
Increase the use of language Provide opportunities and support
IF We want to see improved child comprehension and production outcomes We need to actively teach these outcomes and not simply expect them to happen!
Improvements will be based on 20 of the Hardware ..and 80 of the Software
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 childs 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
6 - 12 months 4
12 24 months 13
24 36 months 9
36 48 months 5
48 56 months 2
56 68 months 5
68 92 months 2
93 All other children
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 childs 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 outcomesare 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
  childs 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
Childs Name Ashley Sex Female Birthdate 11/11/1987 Todays Date 11/5/2007 Childs Name Ashley Sex Female Birthdate 11/11/1987 Todays Date 11/5/2007 Childs Name Ashley Sex Female Birthdate 11/11/1987 Todays Date 11/5/2007 Childs Name Ashley Sex Female Birthdate 11/11/1987 Todays Date 11/5/2007
Directions Please check the sounds that are in your environment (on the left-hand side). Columns on the right-hand side can be used as an assessment to determine your childs detection and identification of specific sounds. Directions Please check the sounds that are in your environment (on the left-hand side). Columns on the right-hand side can be used as an assessment to determine your childs detection and identification of specific sounds. Directions Please check the sounds that are in your environment (on the left-hand side). Columns on the right-hand side can be used as an assessment to determine your childs detection and identification of specific sounds. Directions Please check the sounds that are in your environment (on the left-hand side). Columns on the right-hand side can be used as an assessment to determine your childs detection and identification of specific sounds.
Sounds in Your Home Community Environment Your Childs Response to the Sounds Your Childs Response to the Sounds Sounds to Work On
Sounds in Your Home Community Environment Detection Identification Sounds to Work On
Home Environment Kitchen and Utility Room X Microwave bell X Oven door opening/closing X Oven/egg timer X Oven temperature setting (beeps) X Refrigerator opening/closing X Drawer opening/closing X Dishwasher X Toast popping up in toaster X Blender/Food Processor ? x ? X X X ? X X ? ? ? X X X ? X X A good majority of the sounds are only identified in context and Ashley following who is doing the task.
18
Training focused on Developmental Progression
Environmental Sounds Speech Sounds/Words in closed sets Speech Sounds/Words in open sets
Detection
Discrimination
Identification
Comprehension
19
Detection We must teach the child to detect
sounds

• Environmental Sounds
• Motivational Objects
• Sounds associated with favorite activities
• Favorite toys use sound

• Familiar Voices
• General awareness
• Mothers voice
• Responding to name
• Responding to expressions

20
Communication Criterion Referenced Assessment

• See Attachment C for Communication Criterion
  Referenced Assessment

21
Communication Criterion Reference Assessment
Directions Please indicate if the child uses skills often, sometimes, or not yet/rarely Directions Please indicate if the child uses skills often, sometimes, or not yet/rarely Directions Please indicate if the child uses skills often, sometimes, or not yet/rarely Directions Please indicate if the child uses skills often, sometimes, or not yet/rarely Directions Please indicate if the child uses skills often, sometimes, or not yet/rarely

Childs Response in Home and/or School Environment EARLY COMMUNICATION Often/ Usually Sometimes Not Yet/ Rarely Skills to Target in Routines
Protests by body movement Attends to Mothers eye gaze or touch Smiles and looks at Mother Indicates joy or happiness Squirms to get down Holds up hands or indicates up Begins to demonstrate anticipation Requests more by body movement Requests more by open hand Requests help Gives a hug/kiss upon request X X X X X ? ? X ? ? ? ? ? ? ? ? ? X ? ? ? ? ? ? ? ? ? X ? ? X X X ? ? ? ? ? ? ? ? ? ? ?
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 childs 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-Cs to implement your childs
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 Sandwichlead 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 childs.
• 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.