cc
clinical associate professor at >> Ithe UW department ofd a
communicative disorders.
students on implantable devices I tbut I come from a clinicalad
background. Prior to coming here in 2010, I
spent several years on the
pediatric CI audiologist at Children's Hospital, Boston and
prior to that I worked with adult CI patients at Mass. Eye
and Ear Infirmary in Boston.
experience with both adults and a lot of experience with the
child cochlear implant
And Jennifer Ploch, who will population.
myself, are here to give you the introduce herself next, and
goes on with you, with your loofamily members, with yourwhat
friends, with your patients on our end.
And so I'll let Jennifer
Good morning, my name is introduce herself.
I work across the street, or Jennifer Ploch.
I work at the University down the street, from Melanie.
I see patients both preoperatively and post
operatively.
the adult population. MyWe're going to talk togetherh
today.
pediatric issues and I'll try to Melanie will address more the
the clinical side of cochlear field thimplantation.issues of
And we're going to be joined
she's going to cover the speech and language aspect of cochleard
implantations.
I am herself at that point.duce
So getting back to your question about how good are
these devices.
it's as good as the team that Myou've got working with your
child or with the patient.
this morning, but you can have a We've talked about this a lot
have a really great surgeon who gets that device in the ear just
right.
programs that device, but if you You can have an audiologist who
place, the device isn't going to don't have the other pieces in
So we really believe that it work.
this work and to make it work really takeswell.llage to make
So as Dr. Gubbels mentioned,
involved, the audiologists there's certainly surgeon
pathologists, we have physicians involved, speech language
Hospital who deal with some of assistants at the University
implantation. the We have social workers.lear
A really critical piece for the kids are the educational
audiologists. We can not send your child to
school unless the people at school know about implants and
know how to help your child.
seeing more and more children kind of enter the mainstream in
school. As their mainstreamed, we have
regular educational teachers who
impaired children. don't know about hearing
the school so when your child So we says, "Mrs. --, myce at
batteries died."
to help. There's got to be someone there
beeping and won't stop." Or, "My speech processor keeps
in place to help with some of those classroom management The educational audiologists are
and to help with FM systems. issues
said, as we have a cochlear We're implant coordinator.bbels
We have program assistants who
We can't even get to the help with the insurance piece.
insurance approval. oAnd certainly OT, physicale
therapists, and other professionals along the way as
needed.
So on the audiology end,
have perspective cochlear oimplant patients, what do youu
do, what do we looking for and
pediatric cochlear implant what tests do we have to do for
One of the things that has candidates.
the country, and certainly in the state of Wisconsin, is that
all children now are being
Their hearing is being screened mandtorially.
they're released from tested the hospital.the time
We have pass or a refer for more
We're catching a lot of children testing at that point.
found to have a hearing loss, that is permanent and profound,
we're finding this out very early.
In fact, the goal now across the
screened by one month of age, to country is to have every child
an answer at three months of age have a full diagnostic test with
aids or amplification fit and havby six months.hearing
And I can speak from experience this actually often happens even
earlier in many places. One of the tests that we do, we
do all sorts of testing when
that first screening and but children come in, often after
them is a brain stem response at any potest.and one of
With a tiny baby, you can't raise their hand and tell you if
they hear a sound so we look at brain waves to see how the
hearing is functioning. We do other some other
objective tests of hearing. Based on the results of that
test, if we found that child
them with hearing aids and has a hearing loss, we will fit
Of course, we'll refer for all monitor their progress.
ancillary services that Jennifer of those other supports and
Should we find that someone has severe to profound hearing loss,
and say they're an infant, or a child, and the family is
interested in learning more about cochlear implants, we
would refer for an evaluation on
I'm going to go into a little amore detail later about what.
exactly we're looking at with children in terms of candidacy
and how we assess those things. And as Dr. Gubbels mentioned,
there's other tests and the surgeon and the imaging that's
done at that point. We also want as to look at a
behavior test of hearing in children.
We want to confirm what we're finding on all of our objective
tests where we put a child
at their physical responses to in a hearing booth or look
That is usually something we can sound.
months of age. start to assess around seven
implant consultation if that the Finally we would do a cochlear
to take that. rThe goal in most centers,ng
although you've heard, there's
ready for implantation by 12 variability, is to have a child
It may vary based on the child, the family, the center, the
physical health, insurance, but that is often the goal.
So as you can imagine, an adult evaluation is a little bit
different.
from audiologists, from other ear, nose and throat physicians,
from family practice physicians.
scheduled for an initial At the UW an adult patient is
three hours. evaluation which lasts about
audiologist going over devices, explaining how the system works.
We do some basic preoperative testing to see if they would be
a candidate for implantation. And then they also meet with the
surgeon to determine if they are
implantation. a If insurance, audiologic andar
medical criteria has been met,
more times before surgery. we see the patients back a few
needs to be done before surgery. So there's more testing that
members, spouses, children, to We also like to meet with family
answering questions, and talking spend a lot of time counseling,
after implantation. And as Dr. Gubbels mentioned
there's imaging that needs to be
further we need to have doinsurance authorizationve
in place. That can be easy, that can be
really hard, depending
That can waylay us a little bit. on the insurance carrier.
baseline testing we do. SWe want to do some middle earf
evaluation, we do a basic hearing test to confirm the
hearing loss. We do a lot of word recognition
testing.
understand speech, both with and We want to see how well people
We need to determine if the whearing aids are providing
people with enough benefit. If not, then the question is can
a cochlear implant provide more benefit.
We make sure that the hearing aids are appropriately fit.
So another question is, would a different hearing aid provide
more benefit. We do otacoustic emission
testing.
inner ear function. TAs Melanie suggested, we dor
auditory brain stem response
children. tIf there are questions abouts
dizziness or balance, we may do some preoperative balance
testing.
lot of time with patients and Agfamily members talking abouta
expectations, the process, and
what their given situation. for
So we mentioned the testing that we do, whether it is be
through brain stem response testing or a traditional hearing
test, and because this comes up when we're going to be talking
more in detail about candidacy
wanted to quickly run through fthis graph here called theI
audiogram.
intimately familiar with what Myou see on the screen.y
It's a plot we use to graph the softest sounds that an
individual can hear.
use this to plot our hearing and All of us in the room, we could
different for every single it would probably it would look
Even people who have, kind of, one of us.
might have a slightly different the same cpicture.of hearing
This is one example.
frequency of sound. Starting from low pitch sound on
the left side going over to high
Down the long way, on the Y-axis pitch sound on the right side.
decibel level, from very, very is the loudness of sound, or
loud at the bottom. soAgain, the lines that arery
plotted on there, the symbols,
of the very softest sounds that arethe individual can hear.ion
Typically, just as kind of a
falls on the 20 line, I don't bknow if that's visible, rightt
around there, and above all the way across, that's considered to
be hearing within the normal or the typical range.
So in this case, this individual, and we want to look
at the Xs and the Os for the
discussing, this individual has a severe to profound hearing
loss. This would be a typical
audiogram or graph of an adult
In some cases, if you see like a cochlear implant candidate.
symbol, the X or the O, littlwith the arrow on it?f the
That just indicates that even when the sound as loud as the
equipment would make it, the
this test could not hear individual that was test taking
Maybe they could feel it, but there was not anything audible.
That's not uncommon in cochlear implant candidates at some
frequencies.
background. SI want to touch a little bitr
more in detail. We talked about in throughout
the morning so I don't belabor
a little more detail about hopefully, but we'll go over in
candidacy. pediatric cochlear implant
the audiogram. One of the things we look at is
factor in determining candidacy that we're going to talk about
later which how clear, or how understandable, words or speech
is. But first to discuss the
audiogram, candidacy is slightly
for the 12 to 24 month old different for the young ones,
When they get a little older, the candidacy expands a little
bit, as you can see.
you have the blue plot in the 90-decibels and louder, that's
qualifying a child with a profound sensorineural
hearing loss. That's the graphical, or the
audiogram, criteria.
hearing loss in children that get a little older as long as
they're not successful with appropriately fit hearing aids.
We'll talk a little bit more
recognition in children, but about how we even look at word
important to look at as well. So in older children, children
ages 2 through 17, we want to make sure that even when they're
appropriately fit with hearing
benefit. aids they're not getting
well with appropriately fit hearing aids, and this is really
variable, then that would be the
If a child is fit appropriately, best route for them.
all of the services that they need to, then a cochlear implant
might not be the best choice for
be something so keep an eye on. tOf course, as we keep saying,ld
high motivation and realistic expectations for the family.
That's a key factor, especially for children who are not
necessarily able to be advocates
Again, the adult group is a little bit different.
As you can see from this graph, adults can have a little bit
better hearing in the lower frequencies and qualify for
cochlear implantation.
U.S. indicates that we have to The key though is FDA in the
from conventional hearing aids. dWhat that exactly is, in thet
adult population, adults are
sentences. tested in a sound booth with
booth with the hearing aids on. SThey're listening to a CD, ad
voice says a sentence and they
hear. have tFDA says that on a they
sentence-level test presented in
to score less than or equal to best aided condition, you have
the ear to be implanted, less 50% othan or equal to 60%t in
in bilaterally, bilaterally or in best aided
condition.
if you have insurance that If you're a Medicare patient or
you have to score worse. follows Medicare guide lines,
equal to 40% of words correct. You have to score less than or
presented 50 dB HL in the sound Test materfield.again, are
So we look at how well people can hear beeps.
Raise your hand when you hear a beep, and children we have
different strategies. The other key factor we look at
is word recognition ability and why we look at that.
When we assess word recognition ability preoperatively to
establish if a person is a
Post operatively we look at it candidate for CI or not.
from the device. to see how they are benefiting
programming. It can give us information about
good in a sound booth then that can give us information about
what we have to change in the map parameters, or the
programming, of the speech processor.
We track progress over time.
audience today who are cochlear implant users and they will tell
you they get pretty tired of
because we make them do it over dand over and over again.s
But we monitor progress, we try to do it at least once a year
with adults so we can just keep an eye on things.
If changes start to occur, then we start looking at issues with
mapping parameters or with the
It also helps speech device.
audiologists to know where these pathologists, educational
to guide their therapies at childschool and elsewhere.nd how
We certainly use it for data
collectpurposes.esearch
So as a pediatric cochlear
I got all the time, especially implant audiologist, a question
child is able to do word prior to the point at which a
you even look at how my child is recognition testing was, how do
early can you even test. understanding words, and how
child's hearing. Later, how can you even test my
of both of those. It is important to also look ats
word recognition ability in children.
It's part of the candidacy
mentioned, it's how we track criteria, and as Jennifer
I'm going to show some examples of pediatric word recognition
testing.
but these are some common tests, There's many tests available,
One of the tests for the and tests I have visuals of.
Early Speech Perception test. This test consists of, not just
pictures, but actually objects
We can look at word recognition or sound recognition ability
even before the child is able to
For example, this test has verbally repeat back words.
One would be an airplane and one little toys that come with it.
teach the child that airplane is a little bunny and you could
them visuals, and visual cues from your face and show them the
airplane and teach them to
the bunny. associate a hop, hop, hop, with
you say it, and hopefully hear They can feel you say it, see
Then you can take away the you have say it.
for the AH versus the visuals anhop hop hop.hem listen
Then once they can identify the toys, check to see if they
are able to, with listening only, tell you the difference
in those two patterns.
that's learned on the path of Tlearning to listen with al
cochlear implant. The children I'm talking about
right now are children who have never really heard sound.
Maybe they've gotten a little bit of audibility through a
hearing aid but there's a lot of
12 months of age who've never childhad access to sound.ed at
It's really different than an adult that has a lifetime of
listening and a remembrance of what sound means.
Children who are implanted and
months, it's like they're ears get their sound turned on at 12
they're starting to learn to are a newborn baby's ears and
We have to tailor the testing atthat we do to be aged.
appropriate, not just for the child's age but the listening
and the hearing age as well.
of a hierarchy or levels of And that tdifficulty.hrough kind
But once the child, either
their hearing age, ages out of with their own age, or with
test difficulty a little test like that, we can make the
Here's an example of a test that's still for young children,
it's just a picture pointing task.
This can be done with listening only or with listen and
visual cues.
listening. Often it's done just through
play with the recording or say a So the audiologist would either
identify out of similar words worwhat word they're hearing. to
Once a child is able to repeat
the task because that's another bpart of it, we want to keepn
their attention and keep it fun,
So we may then be able to move we can up the difficulty again.
Because sentence tests tend to to repeating back a sentence.
hear than a single word, because be more easy to understand and
and your brain can help you kind with a sentence you have context
miss a word hear or there. of fill in the blanks if you
children can repeat back for us. We have some sentence tests that
challenging and move on to have them repeat back single words.
It is really important though to
child. choose the right tests for a
2-year-old that can say words back to you, although most often
that's not the case, and you
still listening for different might havepatterns.-old that's
So you really want to vary the
child's appropriate level of tests and tailor the test to the
sound experience, and we don't vocabulary, of listening, of
vocabulary. waWe want all the tests we'reof
doing with children to be familiar words.
Parents will sometimes ask if their child can review the
list beforehand.
look at the list. We don't want them to go through
the words necessarily, take it
We want to make sure that the words that we're testing with
the family and with the child are familiar.
At this point, from an
to look are see how the child is audiology perspective, we want
postoperatively, with their listening skills alone and not
necessarily test those more executive, or higher up, levels
of functioning that Dr. Edwards was just mentioning.
Adults are a whole lot
recognition testing. easier in terms of word
Over the years there's been a lot of standardized tests that
have been produced and various
tests. audiologists will use various
implant circles, if you're on forums or are reading, the
most recent test that we've used
It's a hearing and noise test. most commonly is it a HINT.
will talk about that. They know what their scores are.
They'll talk to each other and
HINT? sWhat are your hint scores."ur
There's a newer test battery
are utilizing. that's available now that we
testing to some newer tests. We've moved away from HINT
battery for adults has really been a joint effort by all three
manufacturers to, I guess in
testing a little bit more across essence, standardize the
manufacturers. centers and across
technology improves and as we're What was happening was, as the
outcomes, most of our patients seeing better and better
HINT sentences. They're scoring more than 80 or
85% of words correct, and it
where the problem areas were. madeSo there are newer, moresee
difficult test materials
The Consonant-Nucleus-Consonant test is old.
It's been around forever. We're using that a little
bit more. The AZ-Bio sentences are the
newer sentences that we use now.
hearing and noise test that And thewe look at. another
Dr. Gubbels already reviewed
Just examples of the various this.
This me or you? manufactuOkay. devices.
So this has already been
Not going to spend a lot of time reviewed.
I'm going to spend some time on the mapping time line, but
Mapping is what we like to call talprogramming or setting. is.
What the audiologist in the office, to set the sound of the
cochlear implant. Most centers follow a pretty
standardized timeline for follow-up mapping.
As has been mentioned, between
activation there's no sound. the surgery and the initial
approximately a month, although that varies depending on the
patient and the center. We, as audiologists, are really
fortunate to be involved in this
I've been very fortunate to be amazing appointment.
turn on the sound for the first in matime for the patient.get to
Realistic expectations are key
We don't know what any one here.
is going to hear through their particular individual or child
You can make a guess but there's device on day one.
We want to be sure it's not nuncomfortable and that you
slowly ease, particularly children, into hearing for the
first time. But there are patients at the
activation are able to converse.
computer screen, to talk or Iusing an interpreter, toa
face-to-face oral communication with no other support at
an activation.
people say that it just sounds I've heard, this is with adults,
back several weeks later and like beeps and buzzes and come
great progress. With children we don't get as
much feedback at the activation.
and how we map with children in I'll showa little bit.w we test
After that initial activation,
first. we hover pretty closely at
change in the ear. The levels that we set can
someone gets used to that electric-type hearing and having
the electrical current stimulate
change over time. And it changes pretty quickly at
first.
person might come back, after their activation, two or three
times for adjustments.
Maybe ever three months. Then it starts to space out.
are going with the individual, Then depending on how things
months, and then eventually it willto annually.ybe six
This slide is really text heavy.
every detail on the slide. I'm not going to go through
professionals in the crowd or people who are interested in the
more technical details of what
the computer screen when we're in the world we're looking at on
As you can see, we look at a lot setting the maps.
we're making adjustments to someone's cochlear implant.n
I'm going to spend the most time
parameter on here which is the talking about the first
manufacturer uses T and C levels, and that's how I'm going
to describe it today. So clinical mapping, or
programming, really this is what
to be like. dLength of experience, therapy,
all of those additional supports
interpret sound, but the mapping help the brain and the ear
device, that's what determines and how the levels are set with
what kind of electrical stimulation the cochlear implant
is providing. We use slightly different
techniques to determine these levels for children and adults.
One of the primary things that
implant, when you see us pushing we're setting with the cochlear
what a audiologist does, is bsetting the threshold level of
electrical stimulation. The smallest amount of current
that we're putting on to the
amount of current the cochlear nerve, and kind of the maximum
For the purposes of today, I'm implant is providing.
or the threshold, and C level, going to call those the T level,
Different manufacturers use slightly different terms to
discuss those.
defined slightly differently, but it's the same general idea
across manufacturers. We can measure those levels of
sound through beeps on each individual electrode, or we can
play the sound on more than one electrode at once.
It sounds kind of like a
A cochlear implant user would be splatting sound.
I can. able to describe it better than
manufacturers call it a speech They call it a speech burst,
more than one electrode at once burstwith a non-speechlikelating
stimulus. It just putting sound onto a
couple of electrodes. We can also make adjustments in
live mode.
turned on and we are talking and Meaning all electrodes are
before the levels have been set tand saved to the processor.n
With adults, it's pretty easy.
an adult. We can ask them to raise their
hand when they hear the beep. Look for the softest beeps.
Like you would imagine a
Sometimes we have adults count hearing test.
When sounds are very soft, the beeps.
maybe raising your hand, and not sometimes you're listening and
So sometimes we have people scount between one and four
beeps and we vary the number, That way we can really
get it. Okay, did they hear it or were
they maybe just guessing, and we're looking for the point
at which those beeps are herd accurately.
Very, very soft but audible.
the maximum comfort or the In terms of comfortable level,
an electrode, with adults we can loudest level we want to play on
We can use a little rating have them tell us.
We can have them rate with a scale.
Like when you think of a pain scale, how you look at the image
of the 1 to 10 and there's a
do the same kind of thing with happy and a smiley face, we can
We even do that with some children, older children, with a
much more simplified rating scale and it tends to work quite
well for a rating comfort.
the softest sound, a very young Dechild can hear, is a littleor
more challenging with behavior
measurements. bSome of you may have seen ag
child tested in a sound booth and some of you have seen a
child receive cochlear
We use a technique called Visual implant mapping.
young children. RI'm going to show a image of
this, because I think there's a lot of mystery about how do you
even accurately set the settings
I'll get into that in a moment, but that's for the youngest
children. When they get a little older
we're able to play a little listening game.
Visual Reinforcement Audiometry in teeny tiny children,
the 12 month old that gets
They may not know what a sound activated at 13 months.
sound that's coming through the implant, we're playing beeps
through their implant, and we're
sound to a turn toward a teaching them to associate that
A light, a video, or-- and us getting very, very happy.
There's some training involved. At the initial stimulation of a
child, we have some objective information, but we're also
trying to get subjective
child as well. information from the
teaching them to associate We're spending a lot of time
happening that they're hearing, that they may not even know is
hearing at that point, with turning their head and looking
at the response.
is not part of the stimulus, The visual that they're getting
Once we establish that they can independently turn their head
and get that reward, then we start looking for that
measurement at softer and softer
I'm going to show you really levels.
I don't have a mouse. A video of that being done for a
cochlear implant mapping. Maybe.
Is Clark here?
I can do it. >> No, that's okay.
We'll see if this works. [inaudible]
I described it pretty vividly. If not, I can move on.
It's during a cochlear It's too bad.
pretty cute. implant mapping, so it's
activation that I did in Boston. It was at a 12 months old's
Oh, here we go. Her parents put this on YouTube
and gave me permission to use it.
We might not have sound.
lot of-- I'm just going to-- there's a
Sure. >It doesn't hurt.?
Oh, are you okay? >> Yeah.
Okay. I'm just exercising here.
[laughter]
The thing about this, is we won't be able to hear what she
hears anyway. All of the sound during the
mapping is coming straight into the device itself.
It's not audible generally in the room by everyone else.
I'm sorry, I don't know
this computer.
It's okay.
Thank you, so much. Okay, I'm going to go back and
show it one more time.
There was a response where she She's already been conditioned.
then she got her reward. turned her head, and looked and
side of the screen with the There'mapping going on.he left
And all of this time I'm playing
softest beeps that she's beeps and looking for the
That was accurate response, so responding to.
engaged. she got the visual reward, she's
looking at the reinforcer so her We don't want her continually
audiologist entertains her mom, or an assist, or another
device, because often at She has a cap on to cover her
tinies like to pull it off. aThey want to see what in the
world is on their head. So it helped to hold it on, and
she did really, really well with
after that. it anWe'll get back to ourng it
PowerPoint.
With older children it gets a little more straight forward.
We want to keep them entertained
The more information we can get, and engaged.
maps. thWe'll do a little game wherehe
they wait for a beep, they
they put a toy in a pegboard, or listen, and when they hear it
checker in a Connect Four game. We can get really creative.
If they like GI Joe, they can get one of those.
We tailor it to the child.
of toys to keep it entertaining. It's nice to have a big arsenal
not able to give us information But sowith their behavior.ts are
Even without the information I
use some objective tests to was jusset our levels., we can
We've used something through the
What that is, it's using the implant called telemetry.
device, to make a measurement of what's happening in the ear
and with the electrode. Every time someone comes in,
we're measuring what is called
just gives information on, if the electrodes are on, making a
contact, basically if they're functioning.
But we also can use the device
the nerve is responding to to make a measurement of where
That's a neural response. All three manufacturers have the
capability now, built-in, to do this automatically or
semi-automatically with our guidance.
We also can make, that third
something called electronically or evoked stapedial reflexge,
thresholds. It's a middle ear muscle reflex
in response to stimulation from the cochlear implant.
There's a lot of research on
the neural response and the treflex threshold, that theye,
correlate with the mapping
the T and C levels. We're able to use that objective
information, either alone or
information to supplement the in map or maybe even create aior
program for someone who's unable
with behavior. to give us any information
I wanted to show you what we see I just wanted-- this is quick.
Many of you with cochlear implants in the room have sat in
on many mappings and may or may not have seen what we look at.
This is just an image of one of the screens we look at with
cochlear. You can see on the bottom
there's a lot of mumbo jumbo in numbers.
We care a lot about those.
mapping parameters that Those arewe're setting.ifferent
The red, kind of, chili peppers across the screen, those are
those C levels or maximum comfort levels.
That's the maximum amount of
placed on each electrode. In this case, maybe you can see,
there's 22 lines and each of
So what the implant is doing, tyou all probably know by now.
after this morning, it's taking all of the sound in our
environment and it's diluting it
the sound, in different down afrequency regions ontting
different electrodes. This is just an image of how
that's done, from low frequency on the left side, to high
frequency on the right side.
loudest sounds going on to the The red chili peppers are the
pickles, those are the T levels, electrode and the green little
signals, or stimulation, that's anbeing provided on eacht
electrode.
the same. There's actually something being
built into the implants now so
cochlear implants. that kids can't swap their
with a lot of kids with Limplants, you do not want them
getting stimulation that's been set for someone else, because it
could be much, much too loud, scary, harmful, and now there's
protective features that didn't always exit so they can't swap
devices and get stimulation that
It's kind like a fingerprint. Your map is unique to you, just
like your hearing test is.
within this population, the Ahearing tests are more similar
and the maps much more
There's a great variability and it really depends on the
individual how these are set. This is just another image, a
different manufacturer. It happens to be Med-El.
I want to show you, it's the
different number the electrodes, same idea, different company,
over to high. bThis company has 12 electrodes
in the cochlea. 12 electrode pairs actually.
And the colored section of the
and the maximum stimulation on bars represents the threshold
So for some patients this can take several months of work.
It's not something that happens in one session, certainly for
children we might only get one
they've got to come back again. oBut at some point, patients go
back to the sound booth for testing with their implant done
and we do another audiogram.
can hear across the frequency We range now with the speechthey
processor on. So we want to make sure that
people have audibility across the frequency range and that
they're falling in their range
and to help their speech where we would expect them to be
So let's go back to the audiogram on the left that
Melanie showed you in the beginning of the presentation.
Preoperatively this would be a
implant candidate. typical audiogram for a cochlear
people to start responding Post operatively we would expect
and 30-35 dB range would be a bepretty typical result across0
manufacturer. So the implant does not provide
normal hearing. Most people still function with
some degree of hearing loss even
But you can see typically patients may fall preoperatively
around 100-decibels and then
20 and 30. hear somewhere between
know, 80-plus decibels of So whearing which is pretty, you
miraculous. I'm not going to spend a whole
lot of time, Dr. Gubbels
affecting performance. really covered this, the factors
Realistic expectations. IThere are some people who can.
hear and understand speech when the device is initially
activated.
happen. That speech develops over time
and it depends on the patient,
etiology of the hearing loss, but quality of sound improves,
with time.
a year like Dr. Litovsky For some people it can take over
Telephone use is also not automatic.
That is something that some people really have to work on.
There are some patients who are not successful using the
telephone with their cochlear implant.
Music perception can also be a
lot of people some people think rmusic sounds good with their
speech processors, others don't agree.
Can take a lot of training, a lot of dedicated time to get
music perception down.
The Hearing Loss Association of America, we do have a Madison
chapter.
adults, so there's a good group Andright here in Madison.ts,
The Association of the Late Deafened Adults.
There's a lots of pediatric groups on-line.
You can find forums and circles on-line to join.
All manufacturers now have
listening, practice, published self-directed
that have been great. Cochlear produces Hope, Sound
and Way Beyond. Some of the other manufacturers
all have their thing. Hearing Journal, there's
telephone programs, and now Cochlear too is moving
towards Apps that you can download on your computers and
phones. You can do a lot of work,
therapy work, from wherever you are.
Even if you're a Nucleus
the AB website. If you go to the manufacturer's
website, they're all there and
Self-directed listening is great they all have really good stuff.
always the answer. and it's helpful but it's not
from a speech therapist and so A lot of people need more help
to us a little bit more about Michpostoperative rehab andtalk
habilitation.
Thanks Jennifer.
My name is Michelle, I work here Thanks for your attention.
Communicative Disorders and have at the Department of
with individuals with hearing haloss for about 30 years.ng
In my career, what is possible
amplification option has changed for individuals because of this
although this is the last topic of the morning, so thanks for
your patience, it is not the
And in fact, for those least.
commitment to work with professionals who have specialty
expertise, in this area, it makes a lasting impact and may
be something that contributes to
patients who have the cochlear implants. in
So what is aural rehabilitation?
lasts varies if you are a person How it looks and how long it
device can interface with your who had hearing before and the
if you are a child who is brlistening for the first times
after 12 or 13 months, or two or
the world with your other three years,senses.ing sense of
Therefore, for children who are developing their spoken
communication skills, having
vision, the process is often relied very much on touch and
We don't always know what the prognosis is until two to three
years after the child has been
In general, to answer the gentleman's question of what do
we usually say to folks, is with
the world, most children will make month progress compared to
typically developing children.
That may be because of the Many, however, will not.
receive, it may be because of the cochlear implant has not
been mapped by someone with enough experience, or,
unfortunately, but often, because two of out of five
children with hearing loss will are other disabilities, the fact
they're not making month to month progress may be a red
flag that that child may have other difficulties
that contribute.
as the patient, and your family, Certainly what expectations you,
motivation and are going to breffect, kind of, what you'rer
going to highlight in the treatment for aural rehab.
First you're going to want to learn to listen to sounds and
patterns that you have not heard
It's the most intense and often the most structured portion of
aural rehabilitation for adults.
minimize their communication For adults they often want to
frustration is reduced, they may difficulties and once their
Some, however, will report even deif certain other aspects ofy.
their communication do not
with having gotten a cochlear implant because it reduces the
effort for them to be able to successfully speech-read and
their spouses or significant
will report to us that benefit others or children or employers
communication breakdowns when using a cochlear implant.
One of the things that I enjoy
is educating people in their doing with my graduate students
and those of you in Wisconsin should take advantage of looking
at the DPI outreach website for working with professionals who
serve children who are deaf.
people who want not just to have And then finally, there are
okay, they want to be able to theoptimize all of theirork
communication interactions. These are the people who come in
with a star mentality and tend
a longer period of time than to want to continue therapy for
providers will allow. When we're coming up with goals
for spoken communication
different areas or facets of success, it might be in
call domains. We might help the person with a
cochlear implant now that they
meaningful what those sound can patterns are. make
We may want to work on speech at
level, or if I'm speaking rapidly in a New York accent,
maybe I need to learn to monitor
need to say to me, "what did you how quickly I talk so you don't
Okay. Language has to do with both
understanding and producing symbols in either speech or in
writing or in sign language,
choose, and then finally people with cochlear implants may want
to have someone to talk about the differences that the
cochlear implant makes that disappoints them, in terms of
quality of life, and learn if some of the patterns that
contribute to that are just part
because communication odifficulties exist for all ofd
us, not only for people with
So then just briefly, since I know we're running out of time,
the area of hearing, we usually start with individuals with an
implant learning to recognize environmental sounds.
This afternoon you'll hear a
talk about children not learning family of panelists who will
make but the objects that make the sounds that a cow and duck
child. sounds within the home for their
if they have a severe or For adults we might help them,
their implant, to learn to profound hearing loss, and get
stress, both to understand what I think is most interpret and use inflection and
sentence, or to be able to use important in the
a monotone voice. In terms of speech, adults often
ask us, "now that my hearing
loud, are my sounds sounding loss has worsened, am I too
speech therapists? distorted to you as a
slurred and I'm wondering if I'm worried that my speech is
spoken sentences with ease." strangers can understand my
not the main area of being a This fear of adults is usually
an acquired hearing loss, a slow communicator that's affected by
then losing your hearing. pFor children, however, makingnd
the link between listening and
component of aural speech is a very critical
We basically want to teach the habilitation.
speech pathologist coach. So we want them to be able tol
listen to what somebody says to them, talk back and compare.
"Did I match what the adult just
Learning to develop that said."
allows the child or the adult awith the cochlear implant to
guide themselves to make sure that their speech output is it
as precise as it needs to be. That, as case for hearing
children, it's a process that might take three to five years.
Really the area of communication
loss feel affects their quality thaof life is being able tong
understand. I've listed here, and you can
read along, you'll see how many of those first bullets have the
words that understanding and
often eased by getting the face-to-face communication is
for your hearing loss. correct kind of amplification
a cochlear implant. WBeing able to understand words
said in a context, about a topic
a level at which you would like you do orsome training.may be at
Being able to understand, as
And what type of clarification Jennifer said, on the phone.
don't understand, is probably the main way that we, at the UW
Speech and Hearing Clinic, serve
their implant has been mapped. adults even a year or two after
life and there are families who Fiwill come to us asking usof
just to have conversations in which we try to help identify
what do they really value, is it
able to continue to bowl and reading and writing, is it being
it a worry about how the hear what your teammate says, is
There are no stupid questions, cochlear implant will look?
like to discuss at this time. Certainly, we are trying to tap
what is your social, emotional
have appointment time where you wcan share that information.to
For children, they need friendship access to meet other
individuals who are using the same kind of devices, to learn
that not everyone that wears a
and to help them pursue their device has thown.me life path
Their own may include appreciating music, and so I'm
delighted to hear that we might be a site for the hybrid
implant, because that device has
want to appreciate music to be been shown to allow patients who
Another aspect of aural rehabilitation that sometimes
adults want to veer from, because they're afraid of the
top word counseling.
listen to you. Counseling is really our time to
hear if what matters to you is When we listen to you, we try to
current context, and if do you something going on the in
to know about what might be some or it not have the information
demands, particularly for those of you who are raising children.
In working with children, I am
colleagues both at Goodnight proud that my clinical
take what's called an eclectic, Hor we're not going to shove it,
down your throat, approach to working with children.
Some children are able to experience success as listeners
if they're structured.
structure because they won't sit Some don't want or need
A semi-structured approach of some give and take.
You get to decide the topic, but
how you respond as a listener. I as the adult get to help shape
learners and it may be the Some children are natural
daughter, he may have a natural learner, who can do the auditory
feedback loop all on her own, but that might be a learning
style that she brings to bear from the time she got her
cochlear implant map. Those of us who serve children
want to help move them as needed
semi-structure, and a natural listening situation, so that
they can listen as naturally, as effectively, and as
accurately as possible. Finally, for the older children,
young adults, sometimes for an
just be able to say to their older adult who is wanting to
to me when you've got the dish spouse, "would you quit talking
Learning how to advocate for washer on from the kitchen."
the problem worse but really one's self so you're not making
whole person rather than just in terms of your hearing loss is
another area of counseling. There's various intervention
approaches as listed here.
one on one, in group therapy. WeAnd the way that the therapy,
is delivered and the focus
A take home message for families can change.
to those of us who like to in the audience is do reach out
in your listening journey, provide treatment at any point
the surgery, close to the time whether it's before the time of
ahead. of mapping, or in the years
us have had the experience of Inbeing given a gift at the of
holiday time that we know somebody has re-gifted.
They were given it, it was
didn't use it. wrapped up nicely, but they
rehabilitation want you to use Those of us who do aural
device, the brain of the person who has the hearing loss, and
the professionals and family
you can be the communicator membersyou want to be.so that
Thank you for your listening and
[applause]