We are pleased to announce that our SLP chat tonight, Wednesday, October 2, 2002,
will be hosted by Debra Nussbaum, MA, CCC-AUD, who will lead us in a chat about Cochlear
Implants.  Debra Nussbaum, an audiologist, is the Cochlear Implant Education Center
Coordinator at Gallaudet University.  She 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! Tonight we are chatting about Cochlear Implants with our featured guest
         host, Debra Nussbaum, MA, CCC-AUD, Cochlear Implant Education Center Coordinator,
         Gallaudet University.
<Robin>  Lets get started!
<mf>  Thanks, looking forward to it.
<christina>  I'm actually a grad student at Gallaudet now. I'm very interested in the chat tonight.
<Debra Nussbaum>  You'll have to come and see first hand.
<Robin>  Debra, please give us some basic info about cochlear implants(CI).
<Debra Nussbaum>  I work from the educational perspective. I am an audiologist by training.
         I will try to explain about the basic technology.
<Debra Nussbaum>  Are any of you familiar with the technology itself? Then I can see how
         much detail to explain.
<Ellen>  I am not too familiar with the technology.
<KG>  extremely limited knowledge of the technology
<Debra Nussbaum>  The implant is a very sophisticated electronic hearing aid.
<Debra Nussbaum>  Part of the device is implanted surgically and part worn as an external
         speech processor.
<Debra Nussbaum>  It is different from a hearing aid as it bypasses the damaged part of the
         cochlea and presents sound in a different way than a hearing aid.
<Debra Nussbaum>  A hearing aid is limited to amplifying the remaining hair cells in the
         cochlea. The implant can stimulate all areas of the frequency range.
<Debra Nussbaum>  It truly provides more sound to a profoundly deaf person than a hearing
         aid can.
<Debra Nussbaum>  The issue is, however, that how a person responds to the sound is very
         very variable.
<Debra Nussbaum>  Initially, when they first emerged, the persons felt to do the best with
         the CI were those who were older and lost their hearing later in life.
<Debra Nussbaum>  They had experienced sound.
<Robin>  There was a lot of press recently about the former Miss America receiving the CI.
<Debra Nussbaum>  Yes, it has gotten press recently. I have not heard yet how she is doing.
<mf>  Debra, I'm a doctoral student leading a discussion this quarter at my university on
         cochlear implants. I'm wondering if you yourself use a cochlear implant?
<Debra Nussbaum>  I am hearing. I have worked at Gallaudet as an audiologist for 25 years
<mf>  How many people at Gallaudet do you work with that have CI?
<Debra Nussbaum>  I have two staff members with an implant.
<Debra Nussbaum>  We have 13 implanted children and 8 more in the candidacy process.
<Debra Nussbaum>  We are looking at ways to integrate this technology in an environment
         that also uses sign language.
<mf>  What are some of the factors that make CI function so variable?
<Debra Nussbaum>  The variables are many. Age of implantation is one of the biggest factors.
<Debra Nussbaum>  The younger, the better for prelingually deaf individuals.
<christina>  and that's where the controversy comes in
<Debra Nussbaum>  Yes, that is a different story
<Debra Nussbaum>  You want to provide sound at the time when language would be developing
         naturally, not remedially.
<mf>  I understand that they are beginning to implant babies before the first year?
<Debra Nussbaum>  Now the candidacy requirements have moved to 1 year, but in some
         situations it is being done earlier. Depends on the hospital.
<mf>  Who is a good candidate and who is not?
<Debra Nussbaum>  You must have a severe to profound loss and not 'benefit' from a
         traditional hearing aid.
<Debra Nussbaum>  The hearing loss criteria are widening however, if it is believed a
         person would do better with an implant than an aid.
<KG>  Please continue explaining why later implantation was believed to be better initially,
         and how things changed.
<Debra Nussbaum>  As the technology has improved and the risks have lessened more babies
         are having the surgery and the outcomes are better than the children implanted later.
<Debra Nussbaum>  Initially , it was primarily done on later deafened. As the technology
         improved, risks lessened, and younger tried successfully, more families have tried
<Debra Nussbaum>  Older later deafened also continue to benefit as well. It is not as
         successful for someone who has been deaf many years, did not benefit from a hearing
         aid, and then tries to make sense of what they hear. The learning process is tedious
         and inconsistent.
<mf>  What are the contraindications for CI?
<Debra Nussbaum>  The contraindications, if you do not have an eighth (auditory nerve),
         sound can not be transferred to the brain, therefore a person would not be a candidate.
<Debra Nussbaum>  If the cochlea is ossified, it is more difficult to insert the electrodes.
<Debra Nussbaum>  What other types of things would you like to know?
<KG>  There is much talk about the need for therapeutic support, but what exactly is the
         role of the audiologist in the management of individuals with cochlear implants?
<Robin>  good question KG...
<Debra Nussbaum>  After the surgery a person must wait about 4 weeks before the external
         processor can be fit.
<Debra Nussbaum>  The audiologist and SLP are the most integral to the implant success.
<Debra Nussbaum>  Why- the mapping or programming of the device is crucial to its success.
<mf>  can you explain mapping further?
<Debra Nussbaum>  Mapping- the T levels and C levels are adjusted. These are the threshold
         levels and comfort levels for each electrode.
<Debra Nussbaum>  Each person's electrode map is individual.
<Debra Nussbaum>  Different speech proceesing strategies are also available. Some stimulate
         all electrodes at once, some in sequence.
<mf>  How often do these require readjustment?
<mf>  Usually?
<Debra Nussbaum>  In the beginning they require frequent mapping. Initially the kids go
         back every day for 2-3 days. Then once a week, then it spreads out.
<Debra Nussbaum>  The brain has to adjust to the sound. What is loud one day, slowly becomes
         too quiet.
<Debra Nussbaum>  We have the mapping equipment at our school, but the audiologist must receive
         special training to do this and it must be in concert with the hospital center.
<mf>  What is the team approach you use at Gallaudet? Meaning, who are the CI team members
         that help facilitate rehabilitation?
<Debra Nussbaum>  We include counselors, SLPs, Audiologists, psychologists.
<Debra Nussbaum>  and teachers and families of course.
<KG>  I understand that audiologists/SLPs are critical to the success of the device...my
         question is, what exactly is the nature of the therapy that is done with a CI user?
<Debra Nussbaum>  About training
<Debra Nussbaum>  Much of what is done is similar to other auditory training programs used
         with deaf children. More focused attention to speech perception for individual
         phonemes is included.
<Debra Nussbaum>  There are a few special programs we are using. One is called WASP (Word
         Association For Syllable Perception).
<Debra Nussbaum>  Another is from Central Institute for the Deaf called the SPICE (Speech
         Perception Instructional Curriculum and Evaluation).
<Debra Nussbaum>  It is important to use a hierarchy of skill development moving a child
         from awareness of sound to higher level listening skills. It is all just noise to
         them in the beginning.
<Debra Nussbaum>  It is not automatic that a person understands with an implant. For a
         young child, they are starting at square one when they get their implant.
<Debra Nussbaum>  Sometimes, when a child has been using their hearing aid, and change to an
         implant, if they had some awareness of sound before they may regress temporarily
         while they adjust to the new sound.
<Debra Nussbaum>  Our students also use sign language. We are addressing language
         development in both realms.
<KG>  What is it about the nature of the auditory signals from a CI that can lead to poorer
         language acquisition/ sound perception without therapy?
<Debra Nussbaum>  It is not the auditory signal, it is the other impacting factors.
<Debra Nussbaum>  The CI does provide good sound quality, it is up to the brain to intepret it.
<Debra Nussbaum>  Again, young children really do make sense of the sound at a faster rate,
         as this is when language is naturally developing.
<Debra Nussbaum>  More kids are getting it younger now, but we have a whole population of
         kids in our school who have used signing all of their life and did not previously
         benefit from a hearing aid. It is a new world for them and spoken English is a
         foreign language.
<Debra Nussbaum>  Since we have such varied outcomes in our program, we believe that signing
         still helps get langauge to the kids faster for learning and we can still teach the
         listening and talking.
<KG>  How do CI users who used to be hearing but became deaf describe the world of sound
         with a CI?
<Robin>  good question KG
<Debra Nussbaum>  People who have heard, lose their hearing, and then get an implant still
         have individual experiences. But many find it similar after the adjustment period.
         There are different experiences related to music quality.
<Debra Nussbaum>  There is not as much training needed, depending on how long a person went
         without their hearing before the CI.
<Debra Nussbaum>  There are many success stories with the CI, but it is not a miracle. It is
         a tool that must be seen as that- outcomes are variable and it is hard to predict.
<mf>  Yea, but how do they EXPLAIN how they hear/what it sounds like?
<Debra Nussbaum>  In the beginning it may sound mechanical, but the parts of speech are all
         there. After a while many say it sounds as natural as what they remember. It is
         still difficult to listen in noise.
<Debra Nussbaum>  There are many assistive devices to attach to the CI to help listen in
         noisy environments.
<KG>  So formerly hearing adults can often transition relatively easily into using the device?
<Debra Nussbaum>  That is reported to be so.
<Robin>  Is CI being performed in other countries? We had someone from Australia write to us
         wanting to know the primary differences (if any) between US and Australian cochlear
         implant technologies.
<Debra Nussbaum>  There are three manufacturers of CI- Cochlear Corporation, Advanced Bionics,
         and MED El. These companies are all available internationally. The Cochlear Corporation
         is from Australia, therefore probably the most used there.  The technology varies
         slightly between the manufacturers, however, the essential benefits appear similar.
<mf>  Who seems to have the most difficulty with CI?
<KG>  Adults with profound deafness who have never been hearing, I bet.
<Debra Nussbaum>  That's right- post lingually deafened adults who have never heard and did
         not benefit from a hearing aid.
<Debra Nussbaum>  Defining success is the issue. While total use of spoken language for
         communication may be the goal of some, it is not for all.
<Debra Nussbaum>  I am seeing more adults in this situation choose implants.
<KG>  What is the reaction to cochlear implant kids on the campus of Galludet?
<Debra Nussbaum>  They still use sign language, but see the implant as a tool better than a
         hearing aid. It is not effective for total understanding for many, but even for
         environmental sound alerting many like it, or music.
<mf>  Can you elaborate on the DEAF populations attitudes towards CI?
<Debra Nussbaum>  Attitudes are changing at gallaudet, but it has been slow.
<Debra Nussbaum>  We did a survey last year and as knowledge about it increases and more
         deaf adults choose the technology and are still culturally Deaf, there is greater
<Debra Nussbaum>  Unfortunately, there is a vocal minority who may not have full information.
<KG>  Are you seeing many college-age students who have been deaf throughout life now
         choosing the CI?
<Debra Nussbaum>  It is increasing in number, but not quickly.
<Debra Nussbaum>  If you ask 10 deaf people, you will get 10 opinions.
<Debra Nussbaum>  Different issues stir up feelings- for example has anyone heard about the
         FDA notice about CI and possible association to meningitis?
<KG>  No...can you tell us about it?
<Debra Nussbaum>  There have been 50,000 or so people implanted in last 15 years, about 50
         have had meningitis at sometime after the CI. Would they have had meningitis anyway?
         Is it associated? Not sure.
<Debra Nussbaum>  The FDA is bringing it to light, vaccination is being recommended, but the
         risk is still very low.
<Debra Nussbaum>  There has been a lot written recently about this, but it does not seem to
         be a reason not to implant.
<Debra Nussbaum>  I will have a paper posted on our website about it or you can visit the
         websites of any of the three manufacturers (references are on our website which is
<Lester>  Are there any other risk factors associated with CI?
<Debra Nussbaum>  Yes
<Debra Nussbaum>  But many causes of deafness are related to anomolies of the ear which
         could be associated as well.
<Debra Nussbaum>  One CI manufacturer changed part of their implant voluntarily
         (a positioner in the surgically inserted part).
<Debra Nussbaum>  They thought it may possibly have been related.
<KG>  Debra, are you involved in research involving CI users?
<mf>  Are you currently conducting any research? What specifically?
<Debra Nussbaum>  We have been spending the first two years of our center developing
         resources. We will be starting research this year.
<mf>  What do you think is the "hot topic" associated with cochlear implant research?
<Debra Nussbaum>  There is a lot of research from a medical/speech perception perpective.
         We will be looking at the impact of sign language as well in our research as doctors
         tend to tell parents that use of signing will deter spoken language development.
<Debra Nussbaum>  Still trying to figure out, what makes a good candidate before the
         surgery is done, what impacts success.
<KG>  This has been very informative, thank you for sharing your expertise, Debra
<Robin>  Debra, thank you so much for joining us tonight and sharing your insights.
<Debra Nussbaum>  Please feel free to contact me at our center and visit our website,
         http://clerccenter.gallaudet.edu/CIEC/ for more resources
<mf>  Very much appreciated, thanks
<KG>  goodnight
<nancy> thank you for an interesting chat
<Robin>  Good night all, thank you for joining us.
<Debra Nussbaum>  Bye