The big advantage of a cochlear implant over a normal hearing aid is that you are able to hear spoken language and speech sounds more acutely, and this facilitates more natural speech development. The implant is particularly adept at facilitating the perception of certain frequencies of speech and the individual is also able to monitor their own speech more successfully.
When children receive a cochlear implant they will require a huge amount of input from the Speech and Language Pathologist/Therapist, the professional implant team, and the parents/care-givers of the child. For adults acquiring a cochlear implant, it is likely that they once had some hearing and already have speech skills, so any input from professionals may be less demanding.
Normal hearing aids amplify the sound, implants attempt to bypass the damaged parts of the hearing mechanism and take the sounds straight to the auditory nerve. Implants require a surgical procedure to implant an electrode into the cochlea.The whole device is made up of several parts:
Once the operation is over for the child, and the cochlear implant is working, there will be several years work by all those involved with the child to facilitate listening, speech, and language development. There are several aspects of the child’s development and their environment that need to be a focus:
As well as helping the hearing impaired child to communicate, everyone around the child must also have a heightened awareness of their own communication and the communication environment. As communicators with deaf children we must be aware of a number of our own behaviours, including facing the hearing impaired child when communicating, talking clearly so they can see our lip patterns, and when needed, using gesture, sign or visuals to help understanding (with Auditory-Verbal Therapy, which we discuss later, you may actually not follow some of these processes, as you are trying to teach the child to listen and discriminate). We must also pay attention to the physical environment and communicate in an area that is well lit and where there is less background noise.
Hearing impaired children are likely to have difficulty learning language, but implanted children should have a good chance of catching up with their peers provided they are implanted early and have frequent language input from those around them. Be aware that hearing children in the pre-verbal stage get feedback from an adult when they look at things, like a running commentary. It is important to have a joint focus, letting the child explore and control their environment, but you can facilitate language development by sitting with the child and talking about what they are doing. As an adult with a hearing impaired baby, try and respond as often as possible, and try to follow your babies focus (as you would with a hearing baby or young child). Keep bringing your child’s attention to sounds that you can hear.
These areas of communication describe learning the use of language in context, turn taking, attention getting, initiating, responding, repairing, topic maintenance, shared knowledge and inference, facial expression, eye contact, proximity and touch. These are all skills that most of us learn easily in the first few years of life, but they may not evolve naturally for children with hearing impairment. The important point here is, don’t let the deaf child be a passive participant, we want them to learn to turn-take, respond and share their thoughts and feelings. Videoing the hearing impaired individual interacting is a good way to highlight certain skills to them.
Speech development has a number of elements:
Cochlear implanted children will have the benefit of having a device that allows them to “tune into” speech sounds more easily and monitor their own speech. However, there will be a number of keys listening skills the child will need to learn through auditory training before they can develop speech sounds.
Things to remember when communicating with an individual with an implant
It is vitally important that parents are involved in the habilitation of their child immediately following a cochlear implant. Much of this habilitation can be achieved through listening activities. These activities can be done during structured play sessions, or throughout the day while you are doing everyday tasks, such as shopping trips, bath-time etc. It is important to be aware of the language level of your child, and this will depend on the age of the child, their level of understanding, and their auditory abilities prior to the implant. It is vitally important to start training at the right level and not make tasks too difficult, so the child can be motivated by a high success rate during activities. It is also important to note that if the child has previously used sign, we may need to try and avoid using it when we are working on sound discrimination and listening. This might be difficult to do, but we need to train the child’s ear and signing often gives too many clues and so the child relies on the sign language at the expense of focussing on listening.
What to be aware of when carrying out auditory training:
There is a hierarchy of treatment with auditory training, and if you are starting at the beginning with a child that has only recently been aided or implanted, the initial auditory work will just be getting the child to discriminate between sound and no sound. Firstly, a child just needs to hear and react to sounds. Can they tell the difference between no sound and a sound? Do they react with a pause or a look when they hear a new sound? One way to start sound awareness is to encourage the child to wait, with their back to you, then you make a sound with a toy or object (such as shaking a marble in a cup), and see if they react. When the child hears the sound and reacts, praise him. Doing this in a structured activity relies on teaching the child a conditioned response. This means they will respond by looking, touching, holding your hand or even putting a bean in a cup, each time they hear a sound. Initially, although the child may acknowledge sounds, they may not necessarily recognise them. When the child can react to the difference between sound and no sound we work through a number of steps:
An example of a Closed Set word list - shoe, pyjamas, gloves (this group of words has different initial sounds, different vowel sounds, and pyjamas has more syllables). A much harder closed set would be - hat, mat, mouse, house, rat (this group is more difficult as some initial and vowel sounds are the same, there is rhyme, and there are also words with close semantic links e.g. Mouse/rat). An Open Set word list can have an endless list of choices and exposes the child to new words, these tasks are much more difficult.
A newly implanted child is likely to have very little sound knowledge. It is the role of parents and/or caregivers to label these sounds for the child, bring the child’s attention to the sound and have a joint focus. Outside the therapy environment the parent or caregiver should be alerting the child to all sorts of sounds, pointing to the source of sounds, naming the source of sounds, and having a joint focus.
Once the child starts to become aware of their own name and some sounds around them in the environment, it might be time to look at doing some more structured tasks involving pattern perception. Pattern perception refers to a child’s ability to differentiate between long and short sounds, or continuous and interrupted sounds, and later, small words and big words. To start with, we want to perform closed set activities, meaning that the child knows and is aware of all the sounds or words we want them to listen to. For instance, look at a familiar group of toys and name them all so the child is familiar with them. Then choose two toys which vary in name, sound, and syllable length, and without using sign or letting the child lipread, (sit behind or at the side of the child), name one item and see if the child can point to it by listening, discriminating and understanding. Once the child becomes used to the game and adept at discriminating sounds you can do this activity throughout the day, for instance, discriminating between products in a shop, or objects when out for a walk. As the child improves, increase the number of items in the choice from two to three, and so on.
As the child’s skills develop, you can progress to using simple sentences in closed tasks e.g. This can begin with some same/different tasks e.g. 2 sets of the same words, but one set has a different word at the end - “are these 2 sets the same, or different?”
Asking the child to discriminate words in phrases and words with background noise will also facilitate their listening development. Finally, to promote their word knowledge, we offer choices with questions (e.g. “Which one do you write with”), so their auditory comprehension is developed further. Once the child feels confident at this level, we need to start considering open set tasks. Open set tasks begin to introduce new sounds or words that the child is not familiar with. The child will need to discriminate, learn and attempt to articulate them as their skills develop.
One of the most successful approaches for facilitating speech and listening for children with cochlear implants, is Auditory Verbal Therapy. This approach focuses on listening and sound awareness, as this is the most natural and efficient way that children learn speech. With auditory verbal therapy every possible opportunity to listen and learn is used through the day, using the child's environment as a learning tool.
Auditory Verbal Therapy (AVT) involves the family and Speech and LanguageTherapist/Pathologist (SLT) who facilitate the child to learn to talk through listening (as a naturally hearing child would learn). Listening, speech, and language are all developed through active listening activities which become a part of play, education and communication on a daily basis. Parents are encouraged to be the primary facilitators of their child’s listening and speech development.
The process is helped by early diagnosis of hearing impairment and the fitting of hearing aids or a cochlear implant for optimal amplification. Parents also have to be committed to participate and work closely with the relevant professionals. The child learns through listening rather than watching. AVT should be administered by a qualified Auditory-verbal therapist who will guide and work with the parents so that they re-produce therapy activities at home in a natural way. Many of the activities we have discussed earlier will be part of the AVT program.
One of the techniques used in AVT is called an “auditory sandwich” where the therapist sits on the aided side of the child repeating auditory information several times, then presenting a visual clarifier (object, picture etc), and then presenting the auditory information again, making sure to use language that is rich in suprasegmental qualities (e.g. Pitch, prosody etc).
Acoustic highlighting is also used to stimulate the listening environment. This involves using variables such a background noise, distance, complexity and rate of utterance to vary the acoustic conditions and really train the child to listen.
There are a number of levels of development of speech and listening skills following the implant:
This development will not happen overnight and the success of therapy will be dependant on total commitment from the parents, caregivers and educational healthcare team around the child.
At the same time as teaching listening, we also want to promote speech. Trying to get children to repeat or name items on request is not the best way to teach speech, we need to find a way for the child to speak on their own terms, where they are in control and in a relaxed environment with no pressure. We need to provide good models for speech, not only naming things for the child, but also repeating back a correct version of their attempts at speech, and praising them every time they attempt speech.
Once the child is actively listening, discriminating and using some speech we can start to look at some speech therapy ideas that focus on speech as well as listening. Usually it helps if the child is a little older when you want to start speech work, because the younger child is often either unaware of what the therapist is trying to achieve, and/or it is difficult to describe certain concepts such as back and front sounds etc. However, listening activities should still be the priority.
It will take time for the child to develop their new listening skills and speech. We have to remember that for some children it will be as if they have the hearing of a newborn and every sound they hear will be new. A cochlear implant can be very effective at promoting listening and speech skills and many children’s speech will eventually become as good as their peers.
For more information on activities to develop speech and language skills visit the website www.icommunicatetherapy.com
Reproduced with permission.
15-Nov-2015 1:20 PM (AEST)