Mode of Communication After Cochlear Implantation - Case Study Example

Introduction With the use of cochlear implants, competence in spoken language has become a reality, even in profoundly deaf children. Betterspeech perception scores are associated with: onset of deafness at a later age, shorter length of auditory deprivation, younger age at implantation, a longer duration of implant use, as well as the communication mode used in the child’s educational setting (Geers, 2002). For children with hearing impairments there are various educational choices that are available. These include: mainstream or special education class, public or private school programs, speech, sign, or equal communication mode, and individual speech and language therapy (Geers, 2002). The communication mode is a frequently examined educational variable with relation to post-implant benefit; there are two communication mode approaches, oral communication (OC) approaches and total communication (TC) (Geers, 2002). There has been a lot of controversy as to which approach is better. Proponents of the OC approach maintain that dependence on speech and audition for communication is not only critical for achieving maximum auditory benefit, but the constant use of auditory input to monitor speech production and to comprehend spoken language gives the required practice for optimum benefit from a cochlear implant (Geers, 2002). Oral communication uses various methods like cued speech approach (use of manual cues to complement lip-reading) or the auditory–verbal approach (lip-reading is discouraged and child learns to make use of whatever auditory information is available through his or her sensory device to understand speech) (Geers, 2002). Proponents of the TC approach believe that for a child with severe-to-profound deafness, a greater benefit will be obtained when some kind of manually coded English accompanies speech, and the use of a sign system facilitates the easy assimilation of language through the unimpaired visual modality (Geers, 2002). Following this, the child can associate what is heard through the implant with signed representations of language in order to support spoken language development (Geers, 2002). Total communication also uses various methods like programs relying heavily on signed input with less emphasis on speech and English syntax or programs that emphasize speech, audition, and lip-reading with careful adherence to English syntax and morphology (Geers, 2002). This study hypothesizes that oral communication mode leads to a better speech perception outcome after cochlear implantation. Review of literature Osberger et al., 1994, aimed to explore the relationship between communication mode and speech intelligibility in children who used oral or total communication. The study involved 18 children with prelingual deafness. The speech intelligibility of these children was examined after using multichannel cochlear implants for an average of three years. While half of the children used an oral communication program, the other half used a total communication program.  The inclusion criterion for the study was children who were implanted at a young age because it was predicted that they would demonstrate the greatest potential to improve their speech.  A close watch was kept on the variables of age at onset of deafness, age at implantation, and duration of implant use. The children were administered The Beginner’s Intelligibility Test (BIT), which is a test that is specifically developed for young children with profound hearing impairments who are delayed in their speech and language development. The results of the study showed that the mean score for children who used oral communication was 48% (SD=31) and the mean score for children who used total communication was 21% (SD=21).  In other words, the average speech intelligibility score of the children who used oral communication was 27% higher than that of the children who used total communication.  The authors feel that four factors could have been involved that gave children who used oral communication this advantage: (1) The children who used oral communication were surrounded by peers who used speech as their primary means of communication. (2) The teachers who were involved in total communication programs might not have been adequately trained to teach speech to profoundly hearing-impaired children. (3) More time may have been devoted to the direct teaching of speech in both structured and unstructured settings in programs that use oral rather than total communication. (4) Parents and teachers of children who use oral communication could have set a higher expectation than those who used total communication. The authors concluded that children who use total communication do not reach their potential in terms of speech development because of inherent problems in the method of communication.  The findings suggest a weakness in the way total communication has been implemented in many programs. Meyer et al., 1998, studied the perception performance in children with prelingual profound hearing loss using multichannel cochlear implants.  The study aimed to estimate the amount of improvement in speech perception scores based on the degree of hearing loss and communication program (TC vs. OC) in the children using hearing aids; and to compare the observed changes over time in speech perception by children using cochlear implants to the improvements predicted for children with profound hearing loss who use hearing aids. Fifty-eight children with prelingual profound hearing losses who use hearing aids and 74 children with prelingual profound hearing losses who received the Nucleus 22-channel cochlear implant were involved in the study. In the hearing aid group, 31 children were in the oral program and 27 were in the total communication program.  In the cochlear implant group, 37 children were in the oral program and 37 children were in the total communication program.  Two tests were used in the study: the minimal pairs test and the common phrase test. An independent comparison was made for the two communication programs. The results showed that the average scores for the children in oral communication programs using either hearing aids or cochlear implants were slightly higher on the minimal pairs test than the average scores for children in total communications programs.  In the cochlear implant group, the children in oral communication programs performed better on the common phrase test than the children in total communication programs. The authors concluded that even though the effect of communication mode on speech perception scores was not assessed specifically, the children who were educated orally had higher scores than those children who were in the total communication program. Another study by Cullington et al., 2000, found that oral subjects demonstrated significantly less spoken language delay than did subjects using total communication, based on speech perception scores only. Geers, 2002, examined the effects of communication mode, class placement, and therapy on five outcome variables (speech perception, speech production, spoken language, total language, and reading) after controlling for the effects of intervening variables associated with the child, the family, and the implant device. The study included 136 children aged 8 and 9-year old who were implanted by age 5 with the Nucleus 22-channel implant. The results showed that the characteristics of the child and the family (primarily nonverbal IQ) accounted for approximately 20% of the variance in post-implant outcome. Implant characteristics accounted for 24% and educational variables, particularly oral communication mode accounted for 12% of the variance in post-implant outcome. The clinical implication of this study is that auditory, speech, language, and reading skills achieved 4–6 years after cochlear implantation were most strongly associated with nonverbal IQ, implant functioning, and use of an oral communication mode (Geers, 2002). However, some studies report no difference in outcomes for oral settings or those using sign (McDonald Connor et al., 2000). McConkey Robbins et al., 1997, reported roughly equivalent outcomes for 23 cochlear-implanted children (Watson, Archbold, Nikolopoulos, 2006). Connor et al., 2000, examined the relationship between oral or total communication used at children’s schools and children’s consonant-production accuracy and vocabulary development over time.  Children in OC programs demonstrated superior consonant-production accuracy compared to children in TC programs. However, children in the TC group achieved significantly higher receptive spoken vocabulary and demonstrated superior scores and rates of growth on the expressive vocabulary measure (spoken and/or signed) scores than children in the OC group if they received the implant at an earlier age. Regardless of whether children were in the OC or TC group, children who received their implants during preschool demonstrated stronger performance, on all measures over time than children who received their implants during their elementary school years. The results of this study suggest that children may benefit from using cochlear implants regardless of the communication strategy/teaching approach employed by their school. Other studies (Dee, Rapin, Ruben, 1982) indicate that young hearing-impaired TC children appeared to learn and express more language at an earlier age than orally trained children. Sign language facilitated acquisition of communicative oral speech, and sign language combined with speech enhanced the meaningfulness of residual hearing and lip-reading. Discussion Several studies (Osberger et al., 1994; Meyer et al., 1998;Cullington et al., 2000) have shown that children who use oral communication consistently achieve higher speech perception and speech intelligibility levels than do children who use total communication. However, a critical analysis reveals that most studies (Oserberger et al., 1994;Meyer et al., 1998) had a small sample size. A large sample size is needed to provide a representative group size and also enables to compare the efficacy of two or more treatment methods. Small numbers may have an impact on the power of statistical analysis (Polgar& Thomas, 2000.) The pre-implant statuses of the children in the studies were also not covered adequately by most studies. Ideally, studies comparing OC and TC implanted children should report the pre-implant status of the children in each group. Nevertheless, in the study by Osberger et al., 1994, the issue of pre-implant characteristics was carefully controlled. The children were matched for age at onset of deafness, age at implantation and duration of implant use. With these factors held constant across groups, an impressive advantage in speech intelligibility was still demonstrated by the OC children. There is also a possibility that children who were sent to TC programs were deafened at a younger age, received cochlear implants at an older age, were students who failed to progress in oral programs, and had less pre-implant residual hearing. Any of these factors could have favored the results in favor of the children in OC programs. Some studies have also reported no difference between OC and TC, equivalent outcomes or better outcomes with TC, but such studies are few, and clearly, the majority of studies seem to favor an OC approach. McConkey Robbins et al., 1997, reported roughly equivalent outcomes for 23 cochlear-implanted children and Connor et al., 2000, suggest that children may benefit from using cochlear implants regardless of the communication strategy/teaching approach employed by their school. Conclusion This topic is still controversial. While most studies support an OC approach, other studies like Connor et al., 2000 suggest that the mode of communication has no effect on speech perception outcomes after cochlear implant. While most studies show that the OC approach improves speech perception outcomes than children who use total communication, there is a possibility that there were some methodological flaws in these studies, like small sample size, and not considering pre-implant status. The findings could have also favored OC programs because children in the TC programs received implants at an older age or were deafened earlier. Nevertheless, though children with TC do improve their language, listening and speaking skills after implantation, children with OC show a better speech perception outcome after a cochlear implantation. Children in OC programs most often receive an intense, direct training in developing their auditory and speech skills, which leads to better outcomes post-implant. It can be therefore, concluded that at present there is not enough evidence that the mode of communication can affect speech perception outcomes after a cochlear implant. References Connor, CM, Hieber, S, Arts, HA, Zwolan, TA (2000). Speech, Vocabulary, and the Education of Children Using Cochlear Implants: Oral or Total Communication? Journal of Speech, Language, and Hearing Research. 43: 1185–1204. Dee A, Rapin I, Ruben RJ. Speech and language development in a parent-infant total communication program. Ann Otol Rhinol Laryngol Suppl. 1982 Sep-Oct; 97:62-72. Geers, A.E (2002). Factors Affecting the Development of Speech, Language, and Literacy in Children With Early Cochlear Implantation. Language, Speech and Hearing Services in Schools. 33:172–183. Geers, A.E (2002). Cochlear Implants and Education of the Deaf Child. Cullington, H, Hodges, A.V, Butts, S.L, Dolan-Ash, S, Balkany, TJ (2000). Comparison of language ability in children with cochlear implants placed in oral and total communication educational settings. Ann Otol Rhinol Laryngol Suppl. 85:121-3. Meyer, Ted, A., Svirsky, Mario, A., Kirk, Karen, I., Miyamoto, Richard, T (1998). Improvements in Speech Perception by Children with Profound Prelingual Hearing Loss: Effects of Device, Communication Mode, and Chronological Age.  Journal of Speech, Language and Hearing Research. 41: 846-858. Moog, J, Geers, A (1991).  Educational Management of Children with Cochlear Implants.  American Annals of the Deaf. 136 (2): 69-76. Osberger, Mary, J, Robbins, Amy, M, Todd, Susan L, Riley, Allyson, I (1994).  Speech Intelligibility of Children with Cochlear Implants.  The Volta Review. 96 (5). 169-180. Polgar S and Thomas SA (2000). Introduction to research in the health sciences.  4th ed. Edinburgh, Churchill Livingstone; 22, p.278. Watson, LM, Archbold, SM, Nikolopoulos, TP (2006). Children’s communication mode five years after cochlear implantation: changes over time according to age at implant Cochlear Implants Int. 7(2), 77–91. Read More