Cochlear Implants - Digital Media Library
Contents
1. Top Controls program selection control Base Controls r T for W for whisper setting telecoil Parts labeled transmitting coil top controls transmitting cable base controls M for microphone mode setting amp battery cover 11 Clarion Devices Photos courtesy of Advanced Bionics i S Series older model Platinum Series newer model Controls ns a program on off switch LED indicator headpiece jack Parts labeled microphone Photos courtesy of Med El control unit battery pack The Implantation Process z The surgery Cochlear implant surgery is performed under general anesthesia in an outpatient setting and lasts for about 3 4 hours Most children go home the same day or spend no more than one night in the hos pital During the surgery the electrode array is threaded into the inner ear and the re ceiver coil is placed in the drilled out bone crevasse behind the ear A pressure ban dage is placed around the incision Gener ally the incision needs 3 5 weeks to heal before the child can have the external parts fitted However within that time most will fe2. A site with a great breadth of information on hearing impairment includes a easy to locate site map with an entire section dedicated to cochlear implants National Association of the Deaf www nad org The oldest and largest organization representing deaf and hard of hearing Ameri cans promotes public awareness of the Deaf community and provides opportunities for the certification of interpreters and ASL professionals National Campaign of Hearing Health www hearinghealth net Sponsored by the Deafness Research Foundation a campaign committed to putting hearing health on the national agenda by raising awareness improve options for those living with hearing loss and protecting the individuals that are at risk Nat l Institution of Deafness amp Other Comm Disorders www nidcd nih gov An organization set up with the goal of performing research to acquire new knowledge to help prevent detect diagnose and treat disease and disability a free publications section is included containing information on cochlear implants Where Do We Go From Here www gohear org Dedicated to being the best site for families of infants and children diagnosed with a hearing loss and the professionals that work with them 37 Programs for Auditory Training amp Rehab tion Bringing Sound to Life Principles amp Practices of Cochlear Implant Reha bilitation Author M Koch Order from Y
3. Cochlear Implants a tips amp reference guide for teachers working with students using Cls Master s Project Submitted to the Faculty Of the Master of Science Program in Secondary Education Of Students who are Deaf or Hard of Hearing National Technical Institute for the Deaf ROCHESTER INSTITUTE OF TECHNOLOGY By Thomas J Ohl In Partial Fulfillment of the Requirements For the Degree of Master of Science Rochester New York June 12 2003 Approved Project Advisor Project Advisor Program Director Cochlear Implants a tips amp reference guide for teachers working with students using Cls Acknowledgements This booklet is a product of collaboration with per sons whose understanding of the subject far exceeded my own To this end the author would like to thank Josara Wallber and Don Sims for their valuable input time and guidance I want to thank Catherine Clark Coordinator of the NTID cochlear implant team for her willingness to share her vast repertoire of knowl edge and resources To all of the above mentioned without your review and feedback throughout the creation process this booklet would remain far from being complete A special thanks to Dr Gerald Bateman MSSE Pro gram Director and Nora Shannon MSSE Coordina tor of Student Teaching two wonderful role models for teachers Your persistence in making sure I didn t skip out early and constant support since
4. must be practiced in increasingly complex linguistic environments 8 Tasks at the phoneme level should be selected by the teacher based on student s speech production errors Abridged from Chute amp Nevins 1996 p 107 116 25 The average hearing benefit gained from a cochlear implant FREQUENCY IN CYCLES PER SECOND HZ 250 500 1000 2000 4000 8000 125 HEARING LEVEL IN DECIBELS dB Student is able to hear everything above threshold below the plotted line on audiogram 26 Normal auditory dev t Given the fact that the prelingually deafened child s hearing experience at the time of hook up is equivalent to that of a newborn you should expect the same skill development as that of a baby While the student will need to ac celerate through the following stages to catch up to their hearing peers you should be able to observe the following natural progression Use these stages to guide the expectations of your self stu dent and child s parents and the re habilitation program 1 Auditory detection awareness to sounds Target environmental sounds initially Try to imitate the sound slow the rate slightly and exaggerate the intonation and pitch 2 Auditory imitation matching vocal production to sound Focus on pho neme recognition and production Auditory Integration associating sounds with symbols or objects Aim at having the chi
5. T Clark Order from Hope Publishing Inc 1856 North 1200 east North Logan UT 84321 435 752 9533 www hopepubl com Troubleshooting Guide Reprinted from Troubleshooting the Cochlear Implant General Guidelines From Including Children with Cochlear Implants Guidelines for Teachers Moore C Nesbitt A Peters M amp Schery T November 2002 faintenance of the cochlear implant device is a parental responsibility However you should be prepared to troubleshoot and perform minor maintenance changing a cord or battery from time to time Because troubleshooting strategies will vary depending on device and the list of problems that could occur is lengthy this guide addresses general guidelines for those problems you are most likely to encounter in your classroom It is suggested that once you are aware of what cochlear implant your student wears that you immediately contact the appropriate manufacturer to request a more detailed trouble shooting guide specific to your student s device or borrow and copy from the parent Steps to troubleshoot e Make sure the device is on If it is not turn it on or switch it to the proper pro gram map The parent or audiologist should show you this setting e Make sure that the volume and sensitivity dials are at the proper setting The parent or audiologist needs to show you the specific setting for the child e Check the transmitting coil Be sure the coil is securely fit on th
6. act with his or her peers and teacher Providing visual support Because students do gain some benefit fone speechreading e Have the child sit where they can sees your face and oth ers faces if in discussion e Position yourself so that light sources are not behind you e Use overheads and handouts as op posed to the black or white board e For those who use an interpreter place interpreter near teacher and in a visible location Photo courtesy of Oticon 24 Close the classroom door Carpet floors and hang curtains on windows If carpeting is not avail able table and chair feet can be pad ded using old tennis balls Arrange seating so that student is away from the doorway fans over head projectors and heater ac Because implant microphones are directional the student should always sit facing the sound source with the signal directed toward the implanted side of the head Put acoustic tiles on hard reflective walls If you can t convince your school to do this you can hang cloth paper or possibly a corkboard in stead If desktops lift open you can use cork or felt to reduce noise from them opening and closing Consult the school audiologist or SLP to evaluate the physical arrangement with you Modifying instruction Your instructional approach may need to change slightly Be sure to gain the stu dent s attention before initiating a discus sion
7. listening only Speechreading Visually scanning the face and especially the lips of the speaker to understand a spoken message Threshold level T level The minimum level of electrical stimula tion required at each electrode for the child to first hear a sound Volume control Control on CI that adjusts loudness of the sound signal 33 References Articles Books go to your local library to retrieve Bayard S 2003 Mainstream Success Cochlear implants and ALDs are allowing our youth with hearing impairments to learn on a level playing field Advance for Audiolo gists March April 32 34 article Nevins M E amp Chute P M 1996 Children with Cochlear Implants in Educational Set tings Singular Publishing Group Inc book Niparko J K 2001 Kids and Cochlear Implants Getting Connected Alexander Gra ham Bell Association for the Deaf and Hard of Hearing article Teagle H F B amp Moore J A 2002 School Based Services for Children With Cochlear Implants Language Speech and Hearing Services in Schools 33 162 171 article Trautwain P amp Levi A 2000 FM Technology for Young Implantees Audiologists serve vital role in interfacing ALDs with cochlear implants Advance for Audiologists July August 28 30 31 article Web Articles Egan n a Maximizing the Hearing They Have An Auditory Verbal Approach Communications Coordinator at Clarke School Pennsylvania Powerpoint Pre
8. amp Answers The Nucleus 3 cochlear implant system 2002 Making the Most of Your Nucleus Cochlear Implant 2001 Parents Guide A Handbook for Parents Considering a Nucleus Implant 2002 A Teacher s Guide to Nucleus Cochlear Implant Systems 2002 Teacher s Guide The Nucleus Cochlear Implant System 1999 User Manual SPrint 1998 User Manual ESPrit 2001 Med El Corporation COMBI 40 The Next Generation Cochlear Implant System n a Understanding Cochlear Implants n a Cochlear Implant Manufacturers Advanced Bionics Corporation MED EL North America Mann Biomedical Park 2222 E NC Highway 54 25129 Rye Canyon Loop Beta Building Suite 180 Valencia CA 91355 Durham NC 27713 i 800 678 2575 in US and Canada 888 MED EL CI 633 3524 800 678 3575 TTY 919 572 2222 Local IDD www advancedbionics com www medel com email info advancedbionics com email office medel com Cochlear Americas 400 Inverness Parkway Suite 400 Englewood CO 80112 800 523 5798 800 483 3123 TTY www cochlear com 35 Resources Suggested Reading Books The Parents Guide to Cochlear Implants 2002 P Chute amp M E Nevins Gallaudet University Press Questions Teachers Ask A Guide for the Mainstream Teacher with a Hearing Impaired Student 1999 J Winslow Otto to V Kozak Central Institute for the Deaf Learning to Hear Again w a Cochlear Implant 1998 D S Wayner amp J E Abrahamson Hear Again Cochlear
9. complex structures as when trying to increase their acoustic memory 6 Provide context Providing meaning is essential when inte grating sounds Making your classroom context rich could involve the establish ment of daily routines or repeatedly focus ing on key words during your instruction 7 Challenging amp reasonable goals Just as with any student goals are vital in providing a target at which to aim Con sider the child the family s desires and current research Use this information to set auditory goals that will be challenging for the child yet not overwhelming As you move toward the target periodically check back to make sure established skills are maintained Abridged from A Teacher s Guide 2002 p 14 a Why use ALDs Some teachers may assume that ALDs are unnecessary given the fact that the child has an implant However the speech proc essor will still choose to send the loudest signal to the ear Therefore even with the best technology children who are hard of hearing or deaf will hear best when the sound source is within 3 feet and there is no competing noise The purpose of an ALD is to increase the signal to noise ratio by reducing distance sound distortion and room reverberation The child benefits by being less distracted and being better able to concentrate on the teacher When to wear an ALD For newly implanted students hold off on fitting an ALD Do so even if they had been
10. ing loss hearing aids assistive listening devices and audiology speech language pa thology services 36 Suggested Websites cont d Cochlear Implant Central http www geocities com cicentral A site of information and resources about cochlear implants compiled by a graduate student implanted with a Clarion device in 2001 Cochlear Implant Association Inc www cici org A non profit organization implant recipients their families professionals and other individuals interested in cochlear implants provides access to local support groups ad vocacy for people with hearing loss and internet and quarterly publications Council on Education of the Deaf www deafed net An organization devoted to enhancing the learning environment of deaf and hard of hearing students by supporting the professional development and collaboration of teach ers and expanding the resources and opportunities of students Mentor registration discussion boards job searches and publications are offered Deafness Research Foundation www drf org An organization committed to public education and research on hearing detection prevention and intervention site contains several articles about and a helpful Hearing Health Dictionary Hearing Exchange www HearingExchange com An online community for the exchange of ideas and information on hearing loss The Listen Up Web www listen up org
11. structured setting in class room Introduction to closed set listening tasks Alerting to the presence of speech sounds especially the child s name Alerting to environmental sounds Implementation of a wearing program Getting the device turned on as soon as possible and begin alerting to speech 27 Choosing a program model Re habilitation programs for implant children usually ground themselves upon one of three approaches auditory verbal auditory oral or total communication Which approach you choose will depend upon the child parental choice school placement and preferred mode of com munication prior to being implanted While providing a description of each approach is beyond the scope of this booklet it is important that you research and discuss with the child s audiologist and SLP before deciding Implementing the program Regardless of the program model that is chosen make a concerted effort to capi talize on the routines of your classroom and the content of the child s curriculum The tasks you develop must challenge the child auditorily while at the same time not frustrate him or her linguisti cally Encourage your student to fully participate in activities that make use of auditory comprehension Remember in your lessons include Explanation and training of audi tory memory through remembering names association practice and attentiveness e Activities related to rhyme inflec ti
12. your review of the information with them may still be helpful You may also want to communicate with his or her parents to find out if there is any addi tional information they think is beneficial for their child to know regarding the de vice Static electricity Because an implant is an electronic device proper precautions should be taken against static electricity Static electricity poses a danger to the speech processor with the po tential of destroying the processor s MAP s The following pictures illustrate some DO s and DON Ts that you and your student should be mindful of Don t pick up your implant equipment without first discharging possible static electricity build up by touching the sur face that the device is resting on In this picture the student should have touched the metal desk first Do wear your implant cables next to larly you should a your skin under all clothing so that ways touch a person static electricity will most likely go i 7 through your body to the ground If you wear them outside they may brush up against or be drawn to ob jects with high levels of static electric Do remove your ity such as a TV or computer speech processor and headset when ever you are around or before using play equipment likely to build up high levels of static electricity plastic slides tubes and ball pits trampo lines tyes not Don t touch a computer scre
13. High frequency sounds s sh are new to the student and initially may be more difficult to recognize Regardless of whether the student detects or recognizes the sound cor rectly give encouragement All stu dents need to know they are doing a good job listening e Perform the test at both 3 and 6 feet Observational clues that a MAP e Emergence of persistent disruptive or of with drawn behavior Diminished response to environmental sounds e Change in frequency of vocalization voice quality and or vocal intensity e Slow reduction in distance listening Student consistently alters sensitivity setting by more than 2 numeric levels higher or lower Working with the Student After Hookup Monitoring the CI amp MAP Most importantly a daily routine to en sure the device is working properly should be established This daily functional check should involve having the child listen and respond to his or her name and detecting or identifying a set of speech sounds using the Ling six sound speech test Assume the student will respond to sound in a structured environment If they do not or their listening ability decreases suddenly the device should be checked immediately Document any changes that persist or worsen over a period of more than a week Your notes will be valuable information for the implant center school audiologist SLP and parents should they contact you During the first three to six mo
14. Implant Auditory Training Guidebook 1997 D Sindrey Wordplay Publications Cochlear Implants in Children Ethics and Choices 2002 J B Christenson amp I W Leigh Gallaudet University Press Listening Games for Littles 1997 D Sindrey Wordplay Publications Children with Cochlear Implants in Educational Settings 1996 ME Nevins amp P Chute Singular Publishing Group Classroom Goals Guide for Optimizing Auditory Learning Skills 1996 J Firszt amp R Reeder AG Bell Association of the Deaf Suggested Websites Auditory Verbal International Inc www auditory verbal org ay eer A non profit organization of professionals and parents whose principal objective is to promote listening and speaking as a way of life for children and adults who are deaf or hard of hearing heightens awareness of the Auditory Verbal approach through pro viding information newsletters international and regional conferences AG Bell Association www agbell org lt jase An organization of professionals families and oral hearing impaired adults that supports auditory oral communication and education provides information support groups regional and national conferences A catalog of published matereial for profes sionals working with hearing impaired children is available American Speech Language Hearing Association www asha org e A national professional organization that provides general information about hear
15. The processor programmed with a speech coding strategy analyzes selects and digitizes useful parts of the sound i e for speech and music into a coded elec trical signal 4 Coded electrical signal is sent through the transmitting cable to the transmitting coil 5 Transmitter sends code across the skin to the internal receiver stimulator 6 Receiver stimulator converts code into electrical pulses These pulses are targeted to stimulate specific electrodes in a specific manner 7 Electrical pulses are sent to the electrode array to stimulate the remaining healthy nerve fibers 8 The electrical signals are sent via the auditory nerve to the brain There the electrical signals will be interpreted as sounds producing a hearing sensation within microseconds of the microphone picking up the sound A speech coding strategy refers to the technique the speech processor uses to trans late the pitch loudness and timing of sound into the signals the implant sends to the cochlea Why I Need to Know About Implants Expanding FDA criteria Expanding 1990 Today criteria Minimum 2 yrs 12 months AGE ONSET of pre pre amp hearing loss _ linguistic post linguistic jhe DEGREE of profound gt 2 yrs permanent 2100dB severe sensorineural profound hearing loss 270dB lt 2 yrs profound 290dB CHILD 0 Lack of audi speech scores best tory progress aided lt 30 on condition age ap
16. al audiologist to obtain the proper cords through the manufacturer Considerations when coupling e Modifications to the FM may be nec essary so the student can monitor their vocal productions particularly for MSPs or Spectra processors w serial s below 34000 e Certain FM channels are preferred for use with students who use CIs as they are less susceptible to electromag netic interference from fluorescent lighting computers etc e Interference is possible between the speech processor and FM receiver Maximize the distance between the two units given the connecting cord and size of the student If your stu dent reports their FM has static or is buzzing have child move to a differ ent place reposition FM receiver move FM receiver away from speech processor change FM channel re place connecting cord from FM re ceiver to CI speech processor or try using a shorter transmitting cable from the processor to the microphone Being tied into the teacher s dialogue may be appropriate for teacher directed activities but less appropri ate for independent or group activi ties In small groups the child may miss opportunities for incidental lan guage learning if the teacher s voice is the primary signal and the teacher is talking to another group Abridged from A Teacher s Guide 2002 p 18 19 ALDs in the school Be mindful that your student may be one of many children using an ALD in your school Address this i
17. as running Most children actu ally wear their implants for PE class However go to the parents for input re garding its use in PE class as some chil dren may be more susceptible to head injuries and cochlear damage While no extraordinary precautions need to be taken protective headgear should be used when it is available for activities such as biking rollerblading and foot ball Children who play soccer should be cautioned against heading the ball Care of the implant Using the system It is not necessary to completely discharge the rechargeable battery prior to recharg ing it However make sure you have used the batteries for more than 2 3 hours Turn the processor off prior to changing the batteries replacing cords or plugging an ALD into the external jack Keep extra cords and batteries in a predetermined secure place Attach an ear mold the kind used with BTE hearing aids or a mic lock to the micro phone to help it stay in place This is particularly important for children who are naturally more active Make an identification tag for the processor If the outer magnet falls off often contact the parent or audiologist Cleaning the system Do not get sand or dirt into any part of the implant If this happens shake out as much dirt or sand as possible For regular external cleaning wipe gently with a cloth dampened with mild deter gent But before using make sure the device is completely dry Regula
18. day one has been invaluable Thanks for helping me to arrive at this new beginning with a Masters degree in my hand Thank you to Nora for being of help in the final editing stage Also a special vote of thanks to Marty Nelson Nasca Director of the Monroe BOCES 1 Program for Deaf and Hard of Hearing students Thanks for all your effort to help me collect information from those that will benefit most from this booklet Teachers of the Deaf themselves Because of your help their feed back guided me along the design process with a clear focus on what was going to be most practical and helpful for the teacher on the front line To those teachers and audiologists who provided this feed back countless thank you s Cover photos courtesy of Cochlear Americas Advanced Bionics and Med El Table of Contents Photo courtesy of Med EI The Purpose of this Booklet Like a stampede the cochlear implant CI has taken the worlds of deaf and hard of hearing persons by storm From its inception in the mid 1980 s some have embraced the technology as a miracle cure while others have thought of it as cultural genocide Yet today many would argue that the implant has come and is here to stay There are many teachers with students using implants who feel inadequately pre pared to deal with this technology You might be one of them If you are this booklet is for you keep reading This book will provide you with s
19. e head and the magnet is in the proper place Some implant systems have extra magnets or ones with adjustable strength The parent or audiologist should adjust magnets since if they are too strong they can cause pressure sores and if they are too weak it may result in loss of the coil e Check the battery As with hearing aids implant batteries go out Make sure the batteries are fresh and inserted properly or change the battery if it is dead The pro cedure will vary depending on the implant system some use standard batteries while others have rechargeable packs Have extra batteries on hand Do not inter change standard and rechargeable batteries e Check the battery contacts Contacts could be corroded and therefore need to be cleaned A cotton swab and a small amount of rubbing alcohol are useful for clean ing DO NOT USE WATER e Check all the cording This is an important item Cords are the weakest part of the implant with all the wear they get from the environment and the child s movement Check all cording for cracks These usually occur nearest to where the cord connects to the device Change bad cording You should keep a spare cord on hand e Check the microphone for proper functioning Look for debris in the socket Each implant device has a different way of indicating a functioning microphone The manufacturer s guide will give you specifics e g flashing light beep If none of these is helping contact
20. el well enough to resume nor mal activities and return to school When your student returns to your class room they will most likely no longer be wearing a pressure bandage However the area of the child s head where the external implant will later be placed will be shaved Some teachers may choose to prepare the other students for the child s return Others may allow the implant child to explain for him or herself when they return Regardless of your approach it is important you do not allow the implant student to be made fun of or feel rejected by his or her peers Hook up day This is the point at which the student is fitted with the external implant parts the transmitter and processor It usually takes place 4 6 weeks after the surgery at the implant center Before this point the child is unable to hear with the implant Commonly the event is referred to as the child s hook up day or initial stimula tion session On hook up day the MAPing process occurs in which the child s initial listening program or more if the proc essor allows for multiple programs is programmed into the child s speech proc essor This program is designed to provide your student optimal access to the speech spectrum Be aware that many children continue use of conventional amplification i e hearing aid in the un implanted ear What is a MAP A MAP is the listening program stored in the memory of
21. en while sure a tip off might Wearing your implant It is possible be noticing your stu t reduce static electricity around dent s fine hair computers by placing an anti static standing on end shield over the computer monitor screen and anti static mats under the chair keyboard and mouse Photos from Teacher s Guide 1999 Do s and Don ts abridged from A Teacher s Guide 2002 p 725 21 Moisture Moisture including perspiration is dam aging to an implant Therefore precau tions need to be taken They include e Take off the implant before swim ming or showering bathing e Remove or cover the implant with a hat or hood during inclement weather e If processor is worn on the front of the body be careful not to splash wa ter on the implant when using a drinking fountain or washing your hands face e Use Dri Aid to store the device 5 sg om Photo courtesy of Med El If the implant does get wet take the following steps 1 Remove the batteries 2 If dropped in dirty water rinse briefly with running drinking water 3 Shake off as much water as possible 4 Place processor in dry pack and notify the parent If the processor is not working the next day contact the school audiologist or im plant center Abridged from A Teacher s Guide 2002 p 22 Physical activity Even with the risk of moisture the child should not have to stop all physical activ ity such
22. fe of the deaf child physically emotionally and socially Understandably the Deaf com munity saw the implant as a threat to the preservation of their culture Those outside Deaf culture with a medi cal perspective perceived the implant as a miracle device able to restore the hearing of deaf children Their hopes were placed on the device s potential to help a deaf child develop spoken lan guage Many of them failed to agree with the NAD s position arguing it was internally contradictory to maintain that cochlear implants do not work and yet work so well they will eliminate deaf ness The controversy today Through time the controversy has evolved Most dramatically the NAD stated in its 2000 position paper that it recognizes the rights of parents to make informed choices for their deaf and hard of hearing children respects their choice to use cochlear implants and strongly supports the development of the whole child and of language and literacy This change reflected a willingness of the Deaf community to give up some ownership of deaf children and begin investigating the implant within the context of Deaf culture However the 2000 paper also stated many within the medical profession con tinue to view deafness essentially as a disability and abnormality and believe that deaf and hard of hearing individuals need to be fixed by cochlear implants This pathological view must be challenged and correc
23. fficult to predict The teacher though can play a significant role in helping the CI child learn how to use the new sound information the implant provides If you are willing to be patient and de velop auditory skill expertise you will be able to help the child overcome some of these limitations What are the risks associated with an implant and the surgery In addition to the standard risks associated with surgical anesthesia there can be surgical complications or infection of the incision area Other risks include failure of the audi tory nerve to respond complete loss of residual hearing need to avoid MRIs damage of the speech processor program by static electricity distorted sound sensation caused by metal detectors theft detection systems or digital cell phones equipment problems and damage of the internal receiver by head trauma 31 Glossary Assistive listening device ALD A device that when used together with hearing aids or a cochlear implant en hances the signal to noise ratio and the student s ability to hear in difficult listen ing situations Audiogram The product of a hearing test It shows how loud a given tone needs to be in order for the implanted child to be able to hear it Everything above threshold level is able to be heard Auditory learning Developing speech and language skills through the use of residual hearing in naturalistic situations Auditory training Listening exercises often
24. implant experience because teachers can easily monitor the signal e Personal FMs are recommended for students in middle and high school who change classrooms or partici pate in after school activities since they offer the greatest portability e Sound field FMs are easiest requir ing no extra body worn equipment e Telecoil induction loop systems require an extra body worn receiver e Personal FMs can be cumbersome because both the body worn FM receiver and body worn speech processor may be required Though capable of attaching to a BTE im plant the child would still need to wear a body worn FM receiver and patch cord In Fall 2003 BTE Cls will be compatible with the wireless MicroLink FM receiver e Personal FMs provide optimal sig nal to noise ratio e Personal FMs can be used in group discussions However because the coupling renders the implant s ear level microphone inactive the teachers transmitter mic would need to be passed around or a FM confer ence mic placed on the table Coupling refers to the use of a cochlear im plant with any other listening device that has the capability of attaching directly Such devices in clude FMs CD players personal radios tape recorders televisions and computers The patch cord necessary to connect the CI to a particular device will depend upon the device and the brand of implant Because of this it is important that you communicate with the education
25. implanted The cost of re implantation may be covered by warranty or ser vice contracts which vary depending on manufacturer Will current implant children be able to take advantage of future technological advances The near future holds many possibilities in cochlear implant innovation Very likely implants will eventually be fully implantable Bilateral implants amp hybrid devices that combine hearing aids and implants are also foreseeable in the future Whether current implant children will be able to take advantage of these advancements will depend on the type of implant they have Most likely surgery will be required However users of cochlear implants are constantly taking advantage of external and pro gram upgrades Manufacturers are constantly enhancing speech coding strategies and speech processors In these cases new implantation or surgery is not required How much does an implant cost Costs for the pre implant evaluation the implant system surgery and post surgical fit ting and training are generally 50 000 to 70 000 However most private insurance policies and or health plans will provide full or partial coverage Medicare may also pro vide coverage What are the limitations of CIs Cochlear implants cannot help all severe profoundly deaf children They also alone can not ensure satisfactory use and benefit Many factors are involved in the implant child obtaining optimum benefit and thus their success is di
26. ions with sound that is heard a MAP The listening program stored in the memory of the speech processor Minimal pair Two words that differ in a single distinc tive feature or constituent e g bat and pat Ossification The bony growth within the cochlea usu ally due to meningitis which blocks the cochlea and prevents full insertion of the electrode array Prelinguistically deafened Became deaf at birth or an early age be fore little exposure to spoken language Postlinguistically deafened Became deaf at an older age after years of being exposed to spoken language Rehabilitation Instructional activities designed for the re teaching of particular skills i e audition speech language Sensitivity control Control on CI that adjusts which sounds are heard i e higher intensity sounds such as nearby speech vs distant speech and environmental sounds Sensorineural hearing loss Hearing loss caused by damage in the inner ear cochlea Signal to noise ratio The loudness of the sound signal as com pared to the loudness of the background noise in the listening environment The higher the ratio the better the student will be able to hear Speech coding strategy How a speech processor translates the pitch loudness and timing of sound into electrical signals that are sent to the coch lea They include SPEAK n of m ACE CIS amp MPS Speech perception The ability to understand speech through
27. kills and ex pertise related to working with your student My goal in providing you this re source is threefold 1 To enable you to become a teacher that can help your student become a successful i e auditory and speech skill development and independent implant user 2 To prepare you to be an effective consultant to and partner with parents teachers audiologists speech language therapists SLPs and other colleagues in your immediate school environment and 3 To guide you to other resources that will assist you in finding answers to questions not included in this booklet As a teacher myself I believe it is our professional responsibility to meet the needs of our students to the best of our abilities If you have a student using an implant this booklet is a great start and a great resource guide to keep returning to Recognizing the time constraints of a teacher I have attempted to pull to gether a wide breadth of information from multiple sources in an easy to read easy to find format After reading this booklet I hope you agree Tom Ohl The Author magnet electrode array L oe EA Internal components ae ote oe Body worn external ee J iye magnet transmitter coil BTE external transmitter coil with magnet s a LA 7 acc transmitting cable peas A simple definition A cochlear implan
28. ld select an object from a small set of easily dif ferentiable items e g moo for cow hop for bunny Auditory discrimination distinguishing similar sounding words Help student make finer dis tinctions between consonants and vowels by using minimal pairs Auditory Comprehension understanding connected speech Common phrases and exaggerated intonation are a good starting point Good sources are nursery rhymes amp children s songs and sto ries because they are repetitive Incidental Learning via Audition Your goal should not be to teach the student every skill but to target specific skills that can be general ized to different environments Stages abridged from A Teacher s Guide 2002 p 16 Immediate auditory goals to be implemented following hook up If the child e Detects a wide range of speech signals in structured tasks e Discriminates different patterns of speech in structured situations the largest percentage of children will be gin at this level e Wears the processor but shows no auditory awareness e Refuses to wear the device Reprinted from Chute amp Nevins 1996 p 83 Then teaching objective should encourage Responding to name Perceiving pattern contrasts single syllable words vs multi syllable words and or short phrases or sentences vs long phrases or sentences Constant expansion of set of pattern contrasts Carryover of acquired skills demon strated in
29. lect upon the rationale for the recommenda tions you are about to implement These principles are contained in the box to the right the 8 Guiding Principles The development of speech percep tion and production abilities is the primary goal of implantation Therefore meaningful speech should be used as the input for lis tening tasks 2 The goal of any listening activity includes the activation of the speech auditory feedback loop linking listening and speaking Therefore listening activities should always provide an opportunity for a productive response 3 Children need to understand both what they are supposed to do and the language used to tell them what to do for successful auditory work to occur 4 In the past CIs primarily provided all children with suprasegmental speech cues i e rhythm intonation stress Today more have gained access to segmental information i e individual speech sounds Regard less the ability to benefit is sharp ened with specific listening practice 5 If classroom listening is one of the goals of auditory practice then it follows that the content of the audi tory lesson be suggested by the child s classroom curriculum 6 Listening practice should be pro vided with a variety of input units the phoneme sound word phrase sentence and connected discourse 7 There is a complex relationship be tween language and listening skills and thus mastered listening skills
30. lly learn to associate sounds with objects in the environment quickly Your student will learn to do the same as they begin to hear more and more sound Encourage this learning process by prompting them to attend to sounds in your classroom environment such as the bell ringing or someone knocking at the door This sound object association will become a vital foundation 3 Give a chance to listen Even when your student does not respond assume they can hear and just need time to process If a sign visual or gestural clue is necessary for understanding do so Photo courtesy of Med E1 but always end by repeating your question or comment in auditory form This is called making an auditory sand wich auditory first then visual aid end with auditory reinforcement 4 Create a listening environment Make a concerted effort to limit back ground noise i e use Assistive Listening Devices close doors and windows and be willing to adjust your teaching style When lecturing you may need to slow down repeat often and be mindful of how you position and emphasize words 5 Allow early success For many deaf children hearing has been a frustrating challenge frequently leading to failure As a result they tend not to trust their hearing You can help your stu dent succeed by limiting the amount and complexity of the information you provide them Use familiar acoustically contrasting items and move from simple to more
31. ng often Developing Partnerships Photos courtesy of Med EI Involving parents The motivation of the student s family significantly contributes to the success of the student using an implant Given your knowledge you will need to make sure their expectations are appropriate and that they are supporting free time use of the CI unless it must otherwise be taken off Encourage them to continue the same auditory habits being developed in your classroom at home and vice versa In doing so periodically inform them of what is occurring in school and how their child is doing For children who are too young to be responsible for the im plant s hardware a system of regular communication such as a daily journal should be established between the child s home and school Most importantly always reassure them that their input and participation is valu able acknowledging the fact that they know their child best 29 Quick Tips Perform your daily check to make sure the cochlear implant is working properly This should include checking the batteries checking the microphone of the CI need a special adaptor and a functional check responding to name and Ling six sound test Have your student look at you visually and listen as much as possible Use a screener for testing the student s speech perception ability peri odically during activities Use a multidisciplinary approach Develop a good relationship
32. nths it is natural for the child using an implant to need changes in their MAP Be sure your student knows it is a natural and positive result of them becoming more accustomed to sound Because many students will be unfamiliar with the device or unable to provide feed back regarding sound quality it will be your responsibility to monitor the student to identify when MAP changes might be necessary Abridged from A Teacher s Guide 2002 p 15 change may be necessary e Increased requests for repetition or use What or Huh e Slushy production of formerly mastered speech sounds e Omission or confusion of consonants that were formerly present or discriminable e Neutralized vowel production e Presence of physical symptoms such as an eye or facial twitch Making sense of new sound From school bells and screeching chairs to speech at conversational levels every sound your student hears through the im plant system is new You must realize that the sound they are hearing is different from what they heard with their hearing aids It is your job to help them make sense of this new sound Here s how you can help 1 Don t expect initial recognition It is possible the child will need to hear a sound or word many times before recog nizing it Don t be afraid to repeat it for them Be prepared to use your teacher gifted patience 2 Draw their attention to sound Hearing babies natura
33. occurring in drill and practice activities BTE Behind the Ear Cochlear implant that sits behind the ear Cochlea The inner ear where the electrode array is positioned Comfort level C level The highest electrical stimulation level that does not produce an uncomfortable loudness sensation for the child 32 Comprehension The ability to understand sound Coupling The use of a cochlear implant with any other listening device that has the capabil ity of attaching directly Such devices include FMs CD players personal radios tape recorders televisions and computers Detection The ability to hear that a sound is present Discrimination The ability to hear that one sound is the same or different from another Dynamic range The number of units between the thresh old and comfort levels Discourse Connected sentences which may include a set of directions a selection from a story or conversation FM system A type of ALD often used to minimize interference from background noise and improve the signal to noise ratio in the classroom Both sound field and personal direct connect FM systems require the teacher to wear a microphone transmitter Habilitation Instructional activities designed for the initial teaching of particular skills i e audition speech language Identification or Recognition The ability to label a stimulus heard Imitation The ability to match one s own vocal product
34. on intonation and accent Exercises using context clues e Practice in vowel recognition since they are the strongest voiced ele ments of speech Reprinted from Wayner 28 Photo courtesy of Oticon ka es Bridging sign to speech For children who relied on Sign before being implanted the auditory and speech process may be more difficult However research has shown that Sign can be used positively as a bridge Often these chil dren already have a firm foundation in language Therefore use Sign in your instruction to improve the student s un derstanding If your student previously relied on Sign remember e Signing is not enough the child must hear the language in order to integrate it into his spoken language lexicon Always voice when you are signing If you are signing talking you must expect the same of your student Your student will not develop and improve mean length of utterance and speech intelligibility without being expected to talk As you help your student transition to oral communication use these tips Use the child s Sign to help identify sounds words and phrases e Provide activities auditorily as often as possible e When first reducing signs use fa miliar phrases and directions amp cover for key words e Use the auditory sandwich tech nique speech sign speech Abridged from Egan Habits to develop with a Signer Use speech to ge
35. or giving instructions Also before beginning conversation state the topic first Periodically check to make sure the student understands by asking him or her to repeat instructions or concepts In the initial stages some teachers have found setting up a buddy system where a classmate repeats instructions to be beneficial Establishing a buddy note taker and or tape recording lectures for later review may also be helpful Auditory amp Speech Re habilitation What you need to know To help your student obtain optimal benefit for auditory and speech develop ment from his or her device there is some information you will need to know before planning and implementing a re habilitation program e Date of hearing loss onset pre or post lingually deafened e Date of initial amplification how long have they been a CI user Student s level of skill with the im plant at the current point in time e The child s post implant audiogram see page 26 for a model audiogram of the average hearing benefit you can expect from an implant e The child s current MAP program s make sure you are made aware of any MAP changes by the MAPping audiologist Most if not all of this information you will be able to retrieve from the student s audiologist and SLP Guiding principles When planning and developing a pro gram with the speech language patholo gist and audiologist you need to ref
36. ork Press P O Box 504 Timonium MD 21094 Orders 410 560 1557 800 962 2763 www yorkpress com The Developmental Approach to Successful Listening II DASL 2nd Ed 50 plus s h Authors G G Stout amp J V Ert Windle Order from Resource Point Inc 61 Inverness Drive East Suite 100 Englewood CO 80112 800 523 5798 www cochlearcorp com Phonetic Listening Word Lists also available for use with DASL 12 00 plus s h CHATS The Miami Cochlear Implant Auditory amp tactile Skills Curriculum Authors K C Vergara amp L W Miskiel Order from AG Bell Association 3417 Volta Place NW Washington DC 20007 2778 202 337 5220 www agbell org Speech Perception Instructional Curriculum amp Evaluation SPICE Authors J Moog J Berdenstein amp L Davidson Order from Central Institute for the Deaf 818 South Euclid Avenue St Louis MO 6311 314 977 0000 www cid wustl edu 38 Reprinted from Teagle amp Moore 2002 Cochlear Implant Auditory Training Guidebook Author D Sindrey Order from AG Bell Association 3417 Volta Place NW Washington DC 20007 2778 202 337 5220 www agbell org Listening Games for Littles Author D Sindrey 3417 Volta Place NW Washington DC 20007 2778 202 337 5220 www agbell org Ski HI Model A Resource Manual for Family Centered Home Based Programming for Infants Toddlers and Preschool Aged Children With Hearing Impairments Author S Watkins amp
37. propri ate tests Numbers rising The number of implant recipients has steadily increased over the past four years Today there are over 60 000 recipients Manufacturers expect this growth to in crease 20 25 yearly This growth can be attributed primarily to expanding FDA criteria for potential can didates due to advances in technology Since 1990 when children of age two were allowed to be implanted for the first time subsequent changes have lowered the age of implantation to 18 and 12 months in 1998 and 2000 respectively Today s FDA criteria also includes chil dren with severe to profound hearing loss previously only those with profound loss were allowed Though children represent a small percentage of the severe profound population child hearing impairment is thought to be under reported The growth may also be due to changes in disability law Severe profoundly deaf children who might have previously been placed in a residential deaf school are now being mainstreamed under the Least Re strictive Environment provision of the Individuals with Disabilities Education Act IDEA As a result more deaf chil dren are finding themselves in Hearing school environments where the benefit of better speech and auditory skill develop ment is much more advantageous Which of my students might be a CI candidate should answer yes to all Do they have severe profound sensorineural hearing loss nerve deafne
38. r cleaning will prevent dirt build up Clean the device pouch using cold water and mild detergent Storing the System For long term storage remove the batteries Do not store the batteries in the refrig erator Putting a cold battery in a warm processor could cause problems with mois ture condensation For long term storage keep the microphone and processor without the batteries in a DRI AID kit to reduce problems caused by moisture A modified DRI AID kit can be made by putting desiccant inside an air tight plastic container or even a zip lock bag When not being used for a brief period of time place the implant in the storage case or DRI AID kit particularly in humid climates labeled with the child s name Abridged from A Teacher s Guide 2002 p 22 and Parents Guide 2002 p 25 26 23 The Classroom Environment Improving acoustics Several modifications can be made to re duce noise and heighten your student s ability to hear in the classroom The challenge What makes a classroom so challenging for a child using a cochlear implant Simply put acoustics Your student is no different from a child who uses hearing aids in that their sensory aids are often not enough to overcome the adverse and com peting noise found in the learning envi ronment Thus you must be willing to modify your room to improve the implant child s abi to hear ultimately increas ing his ability to communicate and inter
39. sentation Madell J Chute P M amp Kooper R 2002 Making the Connection FM Systems and Cochlear Implants American Speech Language Hearing Association Retrieved Feb 23 2003 from http www professional asha org news 0209 10b cfm N A 2000 The Ling Six Sound Test John Tracy Clinic Retrieved May 28 2003 from http www jtc org family_services correspondence SpecialPapers LingSixSounds PDF NAD Cochlear Implant Committee Oct 6 2000 NAD Position Statement on Cochlear Implants Retrieved Dec 13 2002 from http www nad org infocenter newsroom positions Cochlear Implants html Rawlinson S 2000 Serving Deaf Students Who Have Cochlear Implants NETAC Teacher Tipsheet Retrieved Feb 23 2003 from http www netac rit edu downloads TPSHT_Cochlear_Implants pdf Thomas M amp Rick M 2002 Cochlear Implants Fact Sheet American Speech Language Hearing Association Retrieved Feb 23 2003 from http www asha org press cochlear_facts cfm Wayner D n a Learning to Hear Again Cochlear Implant Audiologic Rehabilitation Guide for Adults Retrieved Dec 17 2002 from http www audiologyonline com audiology newroot ceus showclass asp id 85 Manufacturer Booklets contact appropriate manufacturer to retrieve Advanced Bionics Introduction to the Clarion CII Bionic Ear System 2002 Device Fitting Manual 2001 Cochlear Americas A Guide for those considering a cochlear implant 2002 Issues
40. ss in both ears Are they failing to progress in the development of auditory skills Are they receiving little or no benefit from traditional amplification hearing aids FM Are they healthy no contraindications Is the student and family highly motivated and do they have appropriate expectations Is appropriate aural oral support stimulation available in the school 8 Candidacy needs to be determined collaboratively teacher audiologist SLP etc The historical controversy Throughout the history of deaf educa tion there has been a strong pull from two viewpoints the medical view and the cultural view The former views deafness as being abnormal and needing to be fixed with the goal of integrating deaf children into a Hearing society The latter views deafness as simply being different and needing to be ex plored with the goal of helping deaf children find a pride and identity within a unique Deaf culture Since the FDA approved the Nucleus 22 channel cochlear implant for surgi cal implantation in children aged 2 through 17 on June 27 1990 the con troversy has continued In a 1993 position paper the National Association of the Deaf NAD de plored the decision as being unsound on scientific procedural and ethical grounds While making no reference to parents rights to choose they claimed implants to be highly experimental with little evidence of benefit and little con cern over the future quality of li
41. ssue with the entire school staff so that each classroom is on a different frequency and arrangements can be made for students who share activity areas e g gym computer lab Encourage the establishment of a procedure for send ing in broken equipment if one is not al ready in place at the beginning of the year 19 Encouraging Independence s v 34 A Photo courtesy of Oticon 20 What they need to know As a classroom teacher you may only spend one year with your student Even if you are a Teacher of the Deaf TOD students do graduate and move forward in their lives Thus it is your responsibility to encourage your student to become an independent cochlear implant user without your assistance In order to do this there is essential information your student will need to know This includes What are the parts of my implant 2 How does my implant work 3 What can I do and not do with my implant 4 How should I take care of my implant 5 What could go wrong with my implant And what are the warning signs I should be looking for 6 What should I do amp who should I con tact if my implant is not working And is it something I can fix myself What information you share and when you share it will depend on the age abil ity progress and personality of your stu dent Be aware that some of this informa tion may have already been given to them by the implant center or their parents However
42. t or CI is a battery powered electronic device It is designed to improve a child s ability to detect sound and therefore the potential for greater speech understanding when bene fit from hearing aids alone is negligible One part is surgically implanted into the cochlea and surface of the skull while another is worn externally like a hearing aid Unlike a hearing aid that amplifies sounds going to the ear a CI bypasses the dam aged ear hair cells by sending a pro grammed electrical signal to the rema ing healthy nerves in the cochlea This stimulates the auditory nerve directly which can then relay the information to the part of the brain that is responsible for hearing Parts of a typical implant Although CI systems can and do differ manufacturers offer various numbers of channels electrodes and speech coding strategies all implants share the same basic components Internal Components 1 a magnet antenna and receiver stimulator 2 an electrode array External components 3 a microphone 4 a speech processor 5 a transmitting cable 6 a transmitter coil with magnet The external portion may be worn en tirely on the head behind the ear BTE or in combination with a body worn com ponent Photos courtesy of Cochlear Americas How it works Photos courtesy of Cochlear Americas 1 Sound is picked up by a directional microphone 2 Sound is sent from the microphone to the speech processor 3
43. t their attention Expect speech with a point or tap e Continually introduce new vocab e Speak in full sentences e Use figurative language idioms nonsense words expressions e Expect child to learn via hearing Collaboration Without a doubt the information in this booklet alone can be quite overwhelm ing When you think about having to put it into practice it may become even more so Fortunately you don t have to do it alone There are professionals will ing to assist you as you work with your student in the classroom These people include the educational and implant center audiologists and the SLP The educational audiologist is probably the most important as they can be used as a liaison to the other audiologists in volved and a consultant who is familiar with aural rehab and maximizing audi tion The SLP can offer a wealth of knowledge and guidance in developing the speech and language re habilitation program for your student Finally the implant center audiologist can provide you with information about the implant itself along with any changes that are made over time e g MAP The CI sur geon typically has little involvement after the child is cleared post op In return your responsibility is to inform your colleagues of any obvious changes in the child s listening behavior or speech production Also as the teacher take the initiative to get the team work ing together and communicati
44. ted by greater exposure to and inter action with well adjusted successful deaf and hard of hearing individuals Thus it is apparent that the Deaf community has retained its sense of pride and identity Many people have strong opinions about Cls You too may have an opinion Re gardless of your stance though knowl edge that such a controversy exists is in valuable Allow it to spur you on to inves tigate and search out the facts Use this booklet to prepare yourself to be a useful resource to parents and other teachers when they approach you as the expert Be ready _ FDA Approved Cochlear Implants FDA approved devices Today there are three cochlear implant manufacturers providing implant devices in the United States e Cochlear Americas Nucleus devices e Advanced Bionics Clarion devices e Med El Corp COMBI 40 devices To date Nucleus devices have been im planted in children and adults more than the other two combined Photos courtesy of Cochlear Americas Parts Labeled earphone socket external input socket indicator light battery case release latch battery cover Control Buttons headset cable cover release latch LCD panel battery cover release latch select button on off button program button 10 volume or sensitivity control rn
45. the student s speech processor It is created from a computer and special program that measures the child s responses to quiet and louder sounds More specifically it determines the threshold T level and the comfort level C level for each elec trode that has been implanted in the child s cochlea Photo courtesy of Oticon Follow up after hook up After the initial hook up day your stu dent will go back for periodic visits to have their speech processor fine tuned The repeated visits are necessary because it takes time for the hearing nerve to adapt to the new electrical signals from the elec trodes and for the brain to learn how to interpret these signals As time goes on and the MAP becomes more finely tuned the number of adjustments needed will decrease Be aware that you may be asked by the audiologist or parent to monitor which program MAP the child is able to hear best with 15 Ling Six Sound Speech Test 1 Sit at level of the student 3 ft away 2 Cover your mouth with your hand 3 Say in a normal tone of voice ah as in father oo as in moon ee as in key sh as in shoe s as in sock m as in mommy Be sure not to get into a rhythm and each day present in random order 4 Have student respond in a manner that matches your goal If detection raise hand If recognition imitate sound Remember e First focus on student detecting the sounds then recognizing them e
46. using an ALD system prior to get ting the implant They first need experi ence hearing sound with their implant alone This is extremely important for very young children who often show minimal responses during the early im plant stages The FM can be easily cou pled to the CI after you and the audiolo gist are confident in the responses of the student wearing only his implant 18 Using Assistive Listening Devices ALDs ALDs and implants The most common ALD implant pair ings used in schools are an induction neck loop used with a built in or attach able telecoil on a BTE implant Nucleus 3G BTEs have built in tele coils a sound field FM speaker unit usually placed on the child s desk used with a body worn or BTE im plant and a personal direct connect FM re ceiver that inputs directly into the speech processor of a body worn or BTE implant There are two FM systems capable of directly attach ing to an implant the AVR Sonova tion LogiCom Ci and the Phonak MicroLink Troubleshooting ALD systems Check for Weak battery Defective cords buttons or antennas Microphone plugged in incorrectly Channel interference Choosing an ALD In deciding which ALD is appropriate for your student there are several things you need to keep in mind e Sound field FMs e g desktop speakers are recommended for very young children unable to report a malfunction or students with limited
47. with the school audiologist and SLP Communicate with audiologist constantly for information about your student s MAP and listening skills amp how you can promote their auditory development brainstorm creative activities Meet with your student s speech language therapist to develop creative language activities appropriate for their ability Make listening activities FUN Be particularly mindful of touching a student s shoulder BEFORE you touch the implant to avoid damage caused by static electricity Do face the student when talking Do keep eye contact when speaking Do speak clearly Do repeat a word or sentence ex actly If still not understood then choose alternative Phrases to express your thoughts Do monitor environmental noise Do monitor environmental light 30 Don t turn away from the student s view when speaking Don t over exaggerate your speech Don t attempt to talk over loud back ground noise Wait for the noise to stop or move toa quieter place Don t shout when speaking Don t speak with objects in or in front of your mouth Do s and Don ts reprinted from Rawlinson 2000 Frequently Asked Question suss ronis s ssss 20 Will the components of the implant ever need to be changed Implant devices are designed to last a lifetime However as with any man made device there is some risk of failure Almost all who have experienced a device failure are suc cessfully re
48. your school or implant center audiologist and the child s parents They will be able to troubleshoot further and or arrange for repair Supplies that should be on hand at school extra batteries extra cords appropriate devices for checking system e g wand disc 39 National Technical Institute for the Deaf T Rochester Institute of Technology 52 Lomb Memorial Drive Rochester NY 14623 6604 is booklet was submitted In partial fulfillment of the requirements For the degree of Master of Science in Secondary Education Of Students who are Deaf or Hard of Hearing Permission granted to photocopy for educational purposes only 2003 Permission pending for photos courtesy of Oticon
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