Our SLP Student chat tonight, Monday, January 27, 2003, is being hosted by
Debra Nussbaum, MS, CCC-AUD, who will address the topic of cochlear implants.
Debra Nussbaum is the Cochlear Implant Education Center Coordinator, Gallaudet
University.  Ms.Nussbaum, an audiologist, has been a member of the Clerc Center
staff for the past 25 years. She has extensive experience designing and
implementing programming related to auditory and speech skills for deaf students
who use sign language. The Cochlear Implant Education Center is a unit of the
Laurent Clerc National Deaf Education Center at Gallaudet University. The Center
investigates, evaluates, and disseminates effective practices related to cochlear
implant technology and its role in the education and lives of deaf children from
birth through high school.

<Robin> Welcome!  I'm glad you could all be here....lets get started!
<Robin> Tonight we are chatting about cochlear implants with Debra Nussbaum, MS, CCC-AUD,
          Cochlear Implant Education Center Coordinator, Gallaudet University.
<Robin> Debra, could you start with an overview of cochlear implants, definition, etc.?
<rebeccasloat> How long have cochlear implants been being performed?
<DebraNussbaum> Cochlear Implants have been around for about 20 years but earlier ones
          were crude.
<DebraNussbaum> In recent years, technology is greater able to simulate speech.
<DebraNussbaum> Cochlear Implants are being more widely used as a technology with
<DebraNussbaum> Is everyone familiar with them?
<DebraNussbaum> It is a very sophisticated hearing aid and part is surgically implanted.
<DebraNussbaum> The second part is worn externally similar to a hearing aid.
<DebraNussbaum> The cochlea is stimulated electronically instead of acoustically bypassing
          the damaged part of the cochea.
<DebraNussbaum> The surgery is really only the beginning of the road.
<DebraNussbaum> Much training is needed to make the implant successful.
<DebraNussbaum> There is also much controversy related to use of the implant.
<DebraNussbaum> I work at Gallaudet University and initially many Deaf individuals were
          resistant to use of these implants.
<DebraNussbaum> Many Deaf people felt that if a person chose an implant they were not
          accepting a child's deafness and hoping for a miracle cure.
<DebraNussbaum> The implant is now more widely accepted, except very few Deaf people are
          choosing it for their children.
<DebraNussbaum> It is mostly hearing parents who choose to get their child implanted.
<DebraNussbaum> The thing is, the implant really does work better than a hearing aid for
          profoundly deaf children, however, it is not a cure and does not provide the same
          level of benefit for all.
<DebraNussbaum> Not everyone is a candidate either.
<Robin> What are the criteria for being a candidate?
<DebraNussbaum> There are many factors that impact on candidacy.
<DebraNussbaum> The youngest children seem to do the best because they are learning
          developmentally when other babies are learning.
<DebraNussbaum> When I say young I mean 12 months.
<cdgolston> What type of psychological scores does a child need to be considered a good
          candidate for implantation?
<DebraNussbaum> About psych scores, there is not a particular profile that is used.
<DebraNussbaum> Children with lower cognitive functioning are being considered.
<Robin> Lets get back to the factors that impact candidacy.
<DebraNussbaum> Profound loss, 12 months or older.
<DebraNussbaum> Now more children with severe loss are being considered.
<DebraNussbaum> Older children may get some benefit, depending on how much they obtained
          benefit from a hearing aid.
<DebraNussbaum> If they have some sense of "English" through listening, then the implant
          may be more beneficial than for an older student who never heard.
<AdrienneFSU> What professionals are involved in this decision?
<DebraNussbaum> Hopefully there is a team involved from both the hospital and school.
<DebraNussbaum> Unfortunately this is not always the case and Doctors are making the full
<ackcd>  With cochlear implants, is there an important critical period for obtaining them,
          and is there sound research showing a particular critical period?
<DebraNussbaum> If children are identified prior to 6 months, start with some type of
          communication system, sign or spoken, and then are implanted by 12-14 months,
          these children are the most successful.
<DebraNussbaum> The longer the duration of deafness without the implant the harder it is
          to "catch up" but there is still great benefit from it.
<DebraNussbaum> Success is relative.
<DebraNussbaum> The implant truly provides access to sound at close to normal hearing levels.
<DebraNussbaum> But we do not only hear with our ears, but with our brain.
<DebraNussbaum> The sound is meaningless until training occurs.
<DebraNussbaum> In both natural ways and through directed therapy.
<Robin> The training must be intense.....how does it typically start?
<ackcd> How does one go about training the person who receives the cochlear implant to
          distinguish between sounds that are vital and those that are simply background?
<DebraNussbaum> About training, there are strategies and programs that a speech pathologist
          must be trained in to make the implant successful.
<DebraNussbaum> The strategies are similar to working with other children with hearing loss.
<DebraNussbaum> I can direct you to the names of some of the programs through our website.
<ackcd> I would appreciate that.
<DebraNussbaum> We have a resource list to discuss the training resources necessary.
          Go to http//clerccenter.gallaudet.edu/CIEC/
<ackcd> Thanks
<DebraNussbaum> Training begins with many techniques you are already probably aware of.
<DebraNussbaum> First ongoing modeling, language expansion and repetition.
<DebraNussbaum> Think about how many times a typically hearing child hears a word before
          they understand it and express it.
<ackcd> If the child previously used sign, would you at first accompany this modelling with
          signs as well?
<ackcd> Would the association make the transition easier?
<DebraNussbaum> We use the sandwich technique either sign it-say it-sign it or vice versa,
          say it-sign it-say it.
<DebraNussbaum> It depends on the goal
<ackcd> ok
<DebraNussbaum> When the child gets the implant they are listening like a baby. Listening
          skills are very rudimentary and must be developed step by step so that the sound
          becomes functional.
<Erika> Dr. Nussbaum what do you think about the other methodologies in terms of therapy
          techniques? I know that there are several therapy techniques for those with cochlear
          implants...like audiory verbal, total communication, SEE, cued speech...
<DebraNussbaum> I see many children successful using oral aproaches and auditory verbal
          techniques, especially the very young children, however, not everyone has equal
<Erika> Couldn't you say that with all the techniques though? There will be varying degrees
          of success with any technique from person to person.
<DebraNussbaum> I believe each child needs to be looked at individually to see what they
          bring to the process and then decide if sign is needed while the listening develops.
<DebraNussbaum> Many involved with implants however, feel that sign will hold the child
          back from learning to listen.
<Erika> What are your feelings on using sign with a child with a CI?
<ackcd> But it's been shown that even with hearing children, that the use of gestures as a
          means of communication leads to earlier communication skills, acquisition of later
          verbal skills and less frustration.
<DebraNussbaum> I think that it is not for all students with implants but it has a role.
<ackcd> I would think there would be only benefits using sign.
<DebraNussbaum> In a survey from Gallaudet, of about 439 families of implanted students,
          about 2/3 of families were still signing with their implanted child.
<DebraNussbaum> Some doctors feel that the child will become too dependent on the sign and
          not learn to use the implant most effectively.
<Robin> How long does it take a child to adjust to the implant?
<DebraNussbaum> The children adjust amazingly fast to the equipment and show awareness of
          sound immediately.
<DebraNussbaum> There is a process called mapping where the implant is adjusted for each
<DebraNussbaum> Mapping is a process where the child goes repeated adjustment of the
          external components of the implant that contain the computer programs that simulate
          speech,  while the brain adapts to sound.
<DebraNussbaum> Children learn at different rates to actually understand what they hear.
<Robin> Are most parents realistic about what to expect?
<DebraNussbaum> Yes and no.  Even if they say they are, many times they are hoping it will
          do more than we counsel them about.
<DebraNussbaum> Then other times parents have low expectations and are surprised at what
          the technology can do.
<caltman> Do you have any suggestions for counseling parents?
<DebraNussbaum> I try to help families understand the degree of commitment needed to its
<DebraNussbaum> Let the families know that the surgery itself is almost the smallest part
          of it.
<mzaslavs> What is the earliest age that one can receive an implant?
<DebraNussbaum> Implants are being done in the U.S as early as 11-12months.
<mzaslavs> wow
<DebraNussbaum> The FDA recommendation is 12 months.
<DebraNussbaum> It is being done earlier in Europe.
<Robin> Is this covered by insurance?
<DebraNussbaum> It is covered by insurance and medical assistance in most states.
<mzaslavs> Do you believe that they can be implanted any younger or is it physically
<mzaslavs> oh wow...how old in Europe?
<DebraNussbaum> In Europe I have heard it was done as early as 6 months. I did not read
          about this directly however.
<mzaslavs> That is amazing!
<DebraNussbaum> Supposedly, the cochlea itself is at full size at birth (I don't have
          formal documentation of this as a fact).
<mzaslavs> aahhhh
<Erika> What about the ongoing therapy afterward though?
<cdgolston> What would you suggest to a young clinician trying to develop competency
          in aural rehabilitation?
<DebraNussbaum> About therapy
<DebraNussbaum> With a young child, it is providing them with communication naturally,
          singing songs, verbal play, peek a boo.
<DebraNussbaum> Whatever you do with a typical baby, do it and do it more often with an
          implanted baby.
<Erika> No professional therapy?
<DebraNussbaum> Yes, for many families doing language stimulation in a structured way
          does not come naturally.
<DebraNussbaum> Also there are training programs to "play" with the individual phonemes
          to make sure they are being directed to the child and they can play with them.
<DebraNussbaum> One is called the WASP, Word Association for Syllable Perception.
<caltman> I've heard of DASL.
<DebraNussbaum> DASL is another program used as well.
<DebraNussbaum> Objects are associated in play with sound; ahhh for airplane, buh buh for
          boat , etc...
<AdrienneFSU> Very similar to typical speech stimulation activities.
<Robin> Are these training programs presented by an SLP or Audiologist?
<DebraNussbaum> Habilitation specialists with implanted children may be audiologists, SLPs
          or teachers.
<caltman> Are any of these programs specifically designed for children younger than 3?
<DebraNussbaum> We use the WASP under three. Also there is a new notebook/therapy guide
          called My Baby Can Hear.
<DebraNussbaum> I think that is the title, it is for young children and directs families to
          strategies to stimulate listening in young children.
<caltman> Thank you
<Erika> You mentioned before that at Gallaudet you use sign, say, sign.
<Erika> Is that total communication?
<DebraNussbaum> Total communication, historically means using any combination of
          communication strategies, not necessarily at the same time.
<DebraNussbaum> It might mean using ASL and one time, speaking at another.
<DebraNussbaum> So in sense sign-say-sign is a form of total communication. With the
          implanted children we use sign supported speech. We stay in English word order and
          use sign to support the spoken language.
<mzaslavs> I have a question...I just met a 55 yr old woman with a cochlear implant.
<mzaslavs> She received the implant in December and she is only seen by the audiologist
          once a month..is this normal?
<DebraNussbaum> With an adult, it depends on what they bring to the situation.
<DebraNussbaum> Some adults, with good prior listening abilities adjust readily and do not
          need much training.
<DebraNussbaum> Others need the same basic training as a young child.
<DebraNussbaum> Learning to identify the individual phonemes and words from the beginning.
<mzaslavs> oh I see
<Erika> I am working in an auditory verbal classroom right now.
<DebraNussbaum> In the auditory verbal class, are all of the children implanted?
<Erika> no
<Erika> It's a preschool...out of about 10 children, 2 are implanted.
<caltman> What are their age ranges?
<DebraNussbaum> How do the non implanted children do with the AV classroom? 
<Erika> they are late 2s to 4.
<ackcd> Is there such a thing as being too old to get an implant? What are those
<DebraNussbaum> There is not an age when it is "too late", but there are varying
          expectations with the implant, depending on when they became deaf.
<DebraNussbaum> If a prelingually deafened person, is not implanted until late in life
          and never heard, they will probably not become an "oral " communicator.
<ackcd> understandable
<Erika> We have a little boy who was implanted very early, and he acts like a typically
          developing child.
<DebraNussbaum> Why are the other families not considering implants? Do they have too much
          hearing to be a candidate?
<Erika> yes
<Erika> They are all agressively amplified though.
<DebraNussbaum> Now I am finding that most hearing families of our young deaf infants and
          toddlers are considering implants.
<Erika> This is just in the preschool..this program is for all school aged kids.
<Erika> There are more children who have implants that are school age.
<DebraNussbaum> I have not had any Deaf parents chose to implant their children yet.
<Erika> None of our parents are deaf or HOH as far as I know.
<Sherrim> What role should the SLP play when a family is trying to make a decision whether
          to implant their child, especially since the decision is considered so controversial
          in deaf culture?
<DebraNussbaum> The SLP should be part of the team with the audiologist, teacher, family
          and psychologist.
<DebraNussbaum> That is from the school perspective, hopefully they can provide input and
          team with the hospital specialists doctors, etc..
<Sherrim> Do you see it merely as an informative role or something more active?
<DebraNussbaum> More active
<DebraNussbaum> The hospital SLPs may not have training in auditory habilitation, they may
          depend on the school to play this role.
<DebraNussbaum> FYI, we have been trying to find trained SLPs in our program since the fall.
          Most SLPs are not trained to work in Deafness.
<Erika> trained how?
<DebraNussbaum> Trained to understand the process of developing auditory and speech skills
          with deaf children.
<DebraNussbaum> Experience mostly
<Erika> But not necessary through any one methodology?
<DebraNussbaum> Not methodology, but understanding the hierarchy of auditory development,
          how to set goals, and work children moving them from one level to the next.
<DebraNussbaum> How to work on developing speech skills for a child who can not hear.
<Erika> A child without amplification?
<DebraNussbaum> For those who benefit and do not benefit from amplification.
<Erika> I guess what I am getting at, would you want that SLP to know sign?
<DebraNussbaum> Sign would be necessary in our environment, using sign language to
          facilitate the listening and speech development process...
<DebraNussbaum> There are strategies we use.
<DebraNussbaum> One is called Visual Phonics.
<DebraNussbaum> Visual Phonics helps students "see" the different phonemes they can not hear.
<Erika> I've used those with phonological therapy or articulation.
<DebraNussbaum> But back to implants, we use strategies that involve more listening.
<DebraNussbaum> We now have 16 children with implants.
<DebraNussbaum> Three years ago we had only 2.
<DebraNussbaum> I anticipate that with newborn screening expanding we will see the numbers
<DebraNussbaum> As the surgical risk decreases, the technology improves.
<Robin> How many medical centers perform the cochlear implant surgery?
<DebraNussbaum> I don't kknow for sure.
<DebraNussbaum> The websites for each manufacturer are full of information, you may want to
          check there.
<DebraNussbaum> If you have a desire for "free" information see the websites of each
<Robin> How many manufacturers are there?
<DebraNussbaum> There are three manufacturers completing implants in the United States
          (Cochlear Corporation, Advanced Bionics, Med El). They will send promotional
          material at no charge.  Their materials are very well done. 
<DebraNussbaum> There is one video on habilitation techniques from Cochlear Corporation.
          It is excellent.
<DebraNussbaum> You can get to this site from the links on our web page.
<ackcd> Is there any kind of counseling available for those who receive the implant with
          how to deal with situations they would encounter in a deaf community, such as those
          opposed to the implant?
<DebraNussbaum> There is not a specific counseling program, however, there was a video
          called the Sound and The Fury
<AdrienneFSU> Great documentary!!
<DebraNussbaum> There is a website associated with the video and it discusses all of the
          issues related to the deaf culture debate.
<DebraNussbaum> The website is also listed in our Links.
<DebraNussbaum> You can also download the proceedings of a conference we had called
          Cochlear Implants and Sign Language: Putting It All Together.
<ackcd> You have been great help and I've appreciated all your info and shared knowledge
          on the matter.
<Erika> If a family came to you with a 12 month old newly implanted child, what type of
          therapy would you encourage them to use?
<DebraNussbaum> I know that the families I work with strongly recommend AVT. At the same
          time, AVT and sign do not go hand in hand, however, the strategies they use are
          very successful as a therapy approach.
<DebraNussbaum> We incorporate many AVT strategies into our training.
<Erika> I would love to check out other types of therapy...I am being bombarded with AVT
<DebraNussbaum> The other types of therapy are variations of AVT.
<DebraNussbaum> Get the free Cochlear Corporation video on training.  I think it is called
          Learning To Listen.
<DebraNussbaum> It is for parents to show them what to do after the implant.
<Robin> Debra, it is getting late.  Thank you so much for joining us and sharing your
          expertise about Cochlear Implants.
<Robin> We appreciate your time!
<rebeccasloat> Thanks!
<DebraNussbaum> I enjoyed speaking with you.
<Erika> Dr. Nussbaum, I really enjoyed talking with you tonight.
<Erika> It is so timely for me personally.
<DebraNussbaum> I teach an online course as well.
<caltman> thank you!!
<AdrienneFSU> Thank you!
<Erika> Thank you so much for your time
<Erika> It is appreciated.
<Robin> Thank you all for coming!
<DebraNussbaum> Goodnight all
<Erika> Good night
<Robin> goodnight all!!!!!!!!!!!!!!!!!!!!!!!!!!