Lots of attention in the CI world is focused on children implanted young — often before one year of age. Research shows us that children who receive implants before two years of age have a significant advantage in the development of auditory, speech, and language skills (see Svirsky et, al, 2004 and Nicholas and Geers, 2007).
Implantation before twelve months of age is both advantageous and safe (see Waltzman and Roland, 2005). Barring other complicating conditions, and given excellent early intervention and parent support, these children often fly through the process of learning to listen, achieving listening and spoken language milestones at a rate commensurate with their hearing peers. But what about children for whom, for whatever reason(s), this ideal situation does not happen. How late is too late to become a successful cochlear implant user? What do you do when you’re left playing the catch-up game?
Some children who receive cochlear implants outside of the optimum window of implantation age do so because of a shift in hearing thresholds. These children may have been successful hearing aid users whose hearing loss became more severe, necessitating a change to cochlear implants to provided optimum access to sound. These children often do quite well with their CIs after an initial, sometimes rocky, adjustment period to the new type of input and increased sound. Rehabilitation for these children often focuses on moving through the listening hierarchy and practicing auditory exercises with the new CI ear alone for a period of time until its performance is equal to or greater than that of the hearing aid ear.
Children in this group who have become CI candidates and received the device(s) will need therapy focused on moving through the listening hierarchy using the cochlear implant(s) alone (if a hearing aid is worn in the contralateral ear). This new access to sound, especially higher frequencies, also allows the therapist to target goals that were previously inaccessible to the child through audition alone. Children who have had decent, but not complete, access to sound may be missing some grammatical morphemes that include high-frequency sounds like /s/. They may need increased exposure and “teaching” (in a developmental, not remedial, way) of plural -s/-es (cats, boxes), third person singular -s (He runs to the store), and possessive -’s (Grandma‘s dog). Other high frequency/low intensity (high-pitched and quiet) sounds or parts of speech and language that may need tune-ups include regular past tense -ed, speech sounds like s, th, f, and auditory discrimination between sounds that vary in place of production (e.g. t/k).
Other children may not have had earlier access to sound but, for whatever reason, did not receive the cochlear implant(s) until later in childhood. These children may have had difficult early-childhood family situations, parents who had not yet committed to a listening and spoken language outcome, early experiences in other communication methods, or serious medical conditions that required treatment before an elective surgery like cochlear implantation could be considered — all of which are factors that negatively impact our expected listening and spoken language outcomes. “Negatively impact,” however, does not mean “destroy.” While therapy with this population will almost undoubtedly be longer, more intense, and slower-paced, it does not necessarily mean that a listening and spoken language outcome is impossible for this group of children. In their studies of how the brain reacts to auditory input (“cortical auditory evoked potential”), Sharma, Dorman, and Spahr (2002) found the most typical responses in children implanted in the first 3.5 years of life, some limited plasticity in children implanted up to 7 years of age, and dramatically decreased results after that. So, from that research, we can extrapolate that there is some neural plasticity and recovery of typical function (to a degree) children implanted between 3.5-7 years of age, and that therapy to affect auditory pathways in these children is possible.
Some special considerations for listening and spoken language therapy for this population include:
A developmental, not remedial, approach. While this concept is integral to all of Auditory Verbal Therapy, it is especially important to remember for children implanted late. Just because the child is seven and should be speaking in complete sentences doesn’t mean the professionals can ignore the natural progression of language development that he has missed. Therapy that starts from the beginning and rapidly builds to more age-appropriate skills gives the late-implanted child a firm foundation rather than some flashy, more advanced skills, with little to back them up.
Older children need high interest activities, even when working on lower-level tasks. Gear the activity to the child’s developmental age, while the targets embedded within the activity may be more appropriate for her listening age. For example, a child working on discriminating between sets of sounds differing in number of syllables (a low-level auditory skill) may demonstrate this ability by placing stickers on either the “butterfly” or the “star” she is decorating (3 syllables vs. 1 syllable).
These children will need a higher intensity of therapy. Family commitment to a listening and spoken language outcome is crucial for all children with hearing loss, but it is even more key in this at-risk demographic. Parents who desire a listening and spoken language outcome for their children after the ideal window of implantation need to be made fully aware of the uphill battle that they will face and the level of work they will need to do at home to make this outcome possible. It can be done, but families need to go into this 100% aware that it will take everything they have to get their child up to speed.
A supportive educational environment is key. Children implanted late have often begun their formal schooling. Auditory Verbal Therapists must collaborate with classroom teachers to implement support plans that allow the child to function in the least restrictive environment, combining maximal language exposure with activities and instruction at the child’s level. For some late-implanted children, a rigorous auditory-oral school environment may be an appropriate placement. Placement decisions should be made with the input of the child’s entire team (including, and especially, parents).
Regular assessments are important for tracking the progress of all children with cochlear implants, but therapists of children in this late-implanted group must be especially vigilant about their clients’ progress. Goals should be set high and pursued aggressively. With these children, time is of the essence, and if you are not moving forward, you’re losing ground.
Though these children aren’t babies anymore, they still need motherese as a way to “crack the code” of language in the immediate post-activation period.
These children lack listening history and should be given ample opportunity for auditory exposure and experiences to acclimate to a whole new world of sound.
Focus on what matters — these children may have many, many goals and areas in which they need to improve. Choose targets that have the greatest potential to generalize across many settings and will have the largest overall impact on the child’s communication. A rough hierarchy is:
auditory comprehension + language content > language form + overall intelligibility > specific phoneme articulation