The Freedom Cochlear Implant: Another Innovation from Cochlear

Children with Cochlear Implants: fully integrated into the world of

hearing – how and when?

Monika Lehnhardt PhDVarese, April 8th, 2006

In 20 years, an implant will be the treatment of choice for anyone with a hearing loss greater than 50 dB

Dr Jay Rubenstein

March 2004

Vision

"90% of children with a CI will be successfully integrated into mainstream kindergarden and schools, provided they do not have an additional handicap and they get adequate rehabilitation with family support".

Step 1: Is there a hearing loss?

Neonatal Hearing Screening Programmes

Accurate diagnosis

Neonate’s response to sound

DeCasper & Fifer (1980)

Spring and Dale 1977

Eimas et al (1971, 1979)

Infant vocalisations

Stoel-Gammon &

Otomo, 1986

Kent, et al 1987

The Window of Opportunity

Sharma et al, 2002

Ear and Hearing, December 2002

Sharma et al, 2004

Archives of Otolaryngology – Head & Neck Surgery, May 2004

050

100150200250300350400450

0 5 10 15 20 25 30

Age

P1

late

ncy,

ms

Normal limits

14 month old recipient

0

50

100

150

200

250

300

350

0 12 24 36

Age

P1

late

ncy,

ms

Normal limits

13 month old recipient

At CI activation

1 week post CI

1 month post CI

3 months post CI

12 months post CI

Categories of Auditory Performanceref: P Govaerts, C De Beukelaer et al., Neurotology and Audiology 2002 (Antwerp)

response to speech sounds

discrimination of speech sounds

use of telephone

Children with normal hearing

Govaerts, et al. 2002

Otology & Neurology, vol 23; 2002

Age at Mainstream Integration

0

20

40

60

80

100

0 3 5 7

Age (in years)

Per

cent

age

of c

hild

ren

Under 2 yrs2 to 4 yrs

Age at implantation

Maree Doble: PhD thesis in progress (University of Sydney)8 Children, Age of Implantation 8-16 months, enrolled in an AVT program.

LanguageFirst words ⇒ 2- 5 months post activation

Grammatical development ⇒ within normal range @ 2 yrs post activationStandard assessments ⇒language scores ahead of their “Hearing Age” but delayed compared to their Chronological Age

SpeechAll vowels and consonants developing along “normal” expectations ⇒ 18 months post activation. Again, ahead of their “Hearing Age” but delayed compared to their Chronological Age

Geers (2004)*Geers, et al (2003)**

*Archives of Otolaryngology- Head and Neck Surgery, May 2004

*Ear and Hearing, February 2003

Manuel Manrique, et al (2004)

Laryngoscope, August 2004

Reynell

01234567

0 1 2 3 4 5 6 7

Chronological age (years)

"Rey

nell"

age

(yea

rs)

PPVT

01

23

45

67

0 1 2 3 4 5 6 7

Chronolgical age (years)

"Pea

body

" ag

e (y

ears

)

>2 yrs

2 to 6 yrs

Average Language Development

0

12

24

36

48

60

72

84

0 12 24 36 48 60 70 84

AGE (months)

Expr

essi

ve L

angu

age

Age

(m

onth

s) 12-24 months25-36 months37-48 months

Svirsky, et al (2004)

Audiology and Neuro-Otology, vol. 9, 2004

Language development

The deafened child is

“at risk” for listening

& spoken language

skill development

M. Svirsky et al Am. Psy.J. 2000

children

Speech Intelligibility, Svirsky et al.

"The inability to speak intelligibly is a major impediment to integration in mainstream society for many deaf children".

Normal hearing children have 25% intelligible speech at the age of 18 months and 75 -100% at the age of 36 months.

Is there a sensitive period for CI communicative outcomes?

Earlier CI results in earlier development of speech intelligibility shows adevelopmental trajectory Analysis: the curve moves into the right direction, i.e. "younger do better".For the children < 2 y.o. there is a 20% slope improvement, i.e. in 5 years their speech will be totally intelligible. For older children there is only 9% of slope improvement.

The sensitive period starts at 24 months. "

Int J Audiol. 2005 Jul; 44(7): 400 -7.Paediatric cochlear implantation: the views of parents

Interviews with 216 families of children who were implanted at the Nottingham Paediatric Cochlear Implant Programme between 1989 and 2002.

"the biggest area of contention is in respect of their child's education".

Laryngoscope.2004 Sep; 114(9): 1576-81.Outcomes and achievements of students who grew up with access to cochlear implants.

27 prelinguallydeaf young adults who received a CI at the University of Iowa between the ages of 2 and 12 yearsparticipated.•Speech perception and production scores were highly correlated. Achievement test results indicated that scores were within 1 SD from normative data based on hearing individuals. •Over 50% of the college-age eligible students enrolled in college.•The cohort that uses the CI full-time compares favourably with their hearing peers on academic achievement measures.

Pediatr Clin North Am. 2003 Apr;50(2): 341 - 61.viii.Cochlear implantation updateFrancis HW, Niparko JK

"Early identification of hearing loss, early hearing aid use and language intervention, and cochlear implantation by 2 years of age are positive predictors for language acquisition that can approach the levels of normal-hearingchildren.

These are early indications that increased access to mainstream education and gains in quality of life arelong-term benefits that render cochlear implantation a cost-effective intervention.

Ear Hear. 2003 Jun;24 (3): 236 - 47.Exploring the language and literacy outcomes of pediatric cochlear implant users. Spencer LJ, Barker BA, Tomblin JB

"In this study in Iowa 16 peadiatric CI users' language and literacy skills were evaluated and then compared with a reference group of 16 age-matched,normal-hearing children.•The results show, that children with CI performed within 1 SD of the normal-hearing, age-matched children on measures of language comprehension, reading comprehension and writing accuracy.However, the children with CI performed significantly poorer than the children with normal hearing on the expressive "Sentence Formulation" subtest, they also produced fewer words on the written narrative task."

Br J Audiol. 1998 Oct; 32(5): 295-300.Educational placement of deaf children following cochlear implantation. Archbold S, Nikolopoulos TP, O'Donoghue GM, Lutman ME.

This study from Nottingham examined the educational placements before cochlear implantation of 121 children, and the educational placements two years after implantation, of the 48 children who had reached that stage. •It compared the educational placements of those given implants prior to schooling,and those given implantswhen already in an educational setting. •53% of children who were in pre-school at the time of implantation were in mainstream schools two years afterimplantation, whereas only 6% of those who were already in educational placements at the time of implantationwere in mainstream education.

The Canadian Model

•Trends toward mainstreaming vary from province to province and are dependent on numerous factors.

•Over the last two years there has been a growing trend towards mainstreaming the CI children.

• This tends to occur in provinces where mandatory new born hearing screening and early intervention are both encouraged and practised.

• In this environment, many children are no longer accepted as a candidate for a CI unless they provide evidence that they are enrolled and actively involved in an ongoing aural rehabilitation program prior to and following surgery.

•There tends to be a natural progression toward mainstreaming for these children.

•Estimate of mainstreamed children would be as high as 75-80%.

•The trend to encourage oral communication / auditory verbal approaches to rehabilitation across Canada, is largely due to the teachings of many prominent professionals in the AV world, among them, Warren Estabrooks, Judy Simser, Dave Sindrey, Rosalie Yaremko.

92% mainstreamed at the Hear and Say Centre, AustraliaThis case control study with longitudinal design and repeated measures investigated the rate of speech and language development of 29 children with hearing loss (aged 2-6 years, mean pure tone average loss = 74dB HL in the better ear) educated using an Auditory-Verbal approach. Results on a battery of standardised speech and language tests administered at the start of the study and then 9 months later were compared to those of a control group of hearing children matched for language age, gender, intellectual ability and socio-economic level. There were no significant differences in rate of progress between the children with hearing loss educated using the Auditory-Verbal approach and the hearing children on all standardised assessments (p = <0.001). This research will now be extended longitudinally.

Outcomes of an Auditory-Verbal Program for Children with Hearing Loss: A Comparative Study with a Matched Group of Hearing ChildrenDimity DornanSchool of Health and Rehabilitation Sciences, University of Queensland, AustraliaHear and Say Centre, Brisbane, Australia

Schüler im gemeinsamen Unterricht 1994 – 2004 Land Schulen Integration 1994 Integration 2004 Veränderung

1 Baden-Württemberg 13

2 Bayern 10 9,18% 25,22% 16,04%

3 Berlin 3 42,40% 43,21% 0,81%

4 Brandenburg 1 21,72% 34,86% 13,14%

5 Bremen 1 9,75% 46,61% 36,86%

6 Hamburg 1 kAm 20,50% kAm

7 Hessen 4 14,73% 35,22% 20,49%

8 Meckl. - Vorpommern

1 (+1) 33,25% 48,41% 15,16%

9 Niedersachsen 5 kAm 35,30% kAm

10 Rheinland-Pfalz 3 4,95% 30,27% 25,32%

11 Saarland 1 20,85% 41,29% 20,44%

12 Sachsen 3 21,64% 40,00% 18,36%

13 Sachsen-Anhalt 2 kAm 40,60% kAm

14 Schleswig-Holstein 1 kAm 14,63% kAm

15 Thüringen 1 27,40% 69,67% 42,27%

16 Durchschnittswert3 49 kAm 38,38% kAm

Kinder mit CI ohne Zusatzbehinderung und fremde Muttersprache und ihr Anteil in den verschiedenen Schulformen (n= 251)  

23

14

10

30

18

10

3 3

14

23

4

8

2 3

22

30

0

5

10

15

20

25

30

Rege lschule

Berufsschule

Schule für Hg

Schule für Sp

Vorklasse

Rege lk iga

In tegra tiver Kiga

Sonderk iga

Frühförderung

Gesamt0 bis 2:12

Institutionelle Förderung (n=372)

17%39%

1%11% 3% 2%

22%

4%

1%

RegelschuleSchule für HgSchule für SpbSonstige SchulenRegelkigaSonderkigaIntegrativer KigaVorklasseFrühförderung

70%

10%10%10%

Frühförderstelle RegelkigaSonderkiga Integr. KigaRegelschule Schule für Hg.Sonst. Sonderschule

Institutionelle Förderung Institutionelle Förderung Implantationsalter: 0-1 (n=12)

48%

17%

6%6%6%13%

4%

Frühförderstelle RegelkigaSonderkiga Integr. KigaRegelschule Schule für Hg.Sonst. Sonderschule

Institutionelle Förderung Institutionelle Förderung Implantationsalter: 1-2 (n=47)

Institutionelle Förderung Institutionelle Förderung Implantationsalter: 2-3 (n=56)

29%

15%11%5%

14%

26%

Frühförderstelle RegelkigaSonderkiga Integr. KigaRegelschule Schule für Hg.Sonst. Sonderschule

Institutionelle Förderung Institutionelle Förderung Implantationsalter: 3-6 (n=107)

6%10%4%6%

12%

59%

3%

Frühförderstelle RegelkigaSonderkiga Integr. KigaRegelschule Schule für Hg.Sonst. Sonderschule

Institutionelle Förderung Institutionelle Förderung Implantationsalter: 6-8 (n=46)

6%10%4%6%12%

59%

3%

Frühförderstelle RegelkigaSonderkiga Integr. KigaRegelschule Schule für Hg.Sonst. Sonderschule

Institutionelle Förderung Institutionelle Förderung Implantationsalter: >8 (n=47)

30%

66%

4%

Frühförderstelle RegelkigaSonderkiga Integr. KigaRegelschule Schule für Hg.Sonst. Sonderschule

The Wonderful World of Hearing

Thank You

For Your Attention