Download Children and Cochlear Implants

Children & Cochlear Implants
Psychological Evaluation of Implant
Candidates
James H. Johnson, Ph.D., ABPP
Department of Clinical and Health Psychology
University of Florida
Overview and Objectives

The focus of this presentation is on the role of the
psychologist as a member of the cochlear implant
team.
 While the psychologist may often function as a
consultant to the team and may be involved in
providing treatment services for children being
considered for implants, primary attention will
be given to the role of the psychologist in
conducting pre-implant psychological
evaluations of the child.
Overview and Objectives

Here we will highlight –
– the nature of the pre-implant evaluation process
– discuss issues raised in these evaluations that may
argue against implantation
– or that suggest the need for intervention prior to
receiving an implant.

Prior to considering these issues, however, it
would seem useful to take a brief look at
problems that may result in a need for an
implant and the nature of the implant itself.
Functioning of the Normal Ear

The ear has three
sections; the Outer Ear,
the Middle Ear and the
Inner Ear.
 Sound is transmitted as
sound waves from the
environment.
 These are gathered by
the outer ear and sent
down the ear canal to the
eardrum.
Functioning of the Normal Ear

Sound waves cause the
eardrum to vibrate which
sets the three tiny bones
in the middle ear into
motion.
 These are the Hammer
the Anvil and the
Stirrup.
 The motion of these
bones cause fluid in the
inner ear or cochlea to
move.
Functioning of the Normal Ear

Movement of the fluid in
the inner ear causes the
hair cells in the cochlea
to move.
 The hair cells transform
this movement into
electrical impulses.
 These electrical impulses
are transmitted to the
auditory nerve and to the
brain where they are
interpreted as sound.
Sensorineural Hearing Loss





Sometimes normal hearing is impaired due to
sensorineural hearing loss.
This is a hearing loss where – the bones, eardrum and
membranes of the ear are intact but the tiny hair cells
that line the cochlea have been damaged.
When this happens, the damage to the hair cells does
not allow the usual electrical impulses to reach the
remaining nerve fibers.
The nerve fibers then do not have information to send
to the brain.
This is often referred to as “Nerve Deafness”,
Causes of Sensorineural
Hearing Loss

Sensorineural hearing loss can be caused by
a number of factors including
– Genetic factors
– Injury
– Illness
– Natural aging
– Ototoxic drugs, sometimes used to treat life
threatening illness.
What is a Cochlear Implant?

A cochlear implant is an electronic device, that
bypasses the damaged hair cells of the cochlea
and stimulates the auditory nerve directly.
 IT can provide the child with useful “hearing”
and improved communication abilities in the
implant user.
 It is a safe, reliable, and an effective treatment
for profound hearing loss in children (and
adults).
How do Cochlear Implants
Work?

Cochlear implants detect
sounds via an ear level
microphone that sends
these sounds to a wearable
sound processor.
 The processor converts
these sounds to tiny digital
impulses that provide
hearing sensations to the
user.
 Some of the newest sound
processors are small
enough to fit behind a
person's ear.
How do Cochlear Implants Work?

The electronic impulses
from the processor are sent
to a coil or transmitter (halfdollar sized) worn
externally behind the ear
over the implant.
 The coil sends an FM signal
to the implant receiver,
located under the scalp.
 The implant then sends
these sound impulses to a
number of tiny electrodes
within the cochlea (inner
ear).
How do Cochlear Implants Work?

These signals contain
information about the
frequency and loudness
of speech and other
sounds.
 The responses to these
signals are then sent via
the auditory nerve to the
brain where they are
interpreted as sound.
A Fitted Cochlear Implant
The Implant Process

Audiological Evaluation
– Assessment of hearing levels
– Testing with high powered hearing aids
– Speech and language tests to get baseline

Medical Evaluation
– Assess safety of general anesthesia
– Imaging to assess suitability of cochlea and auditory
nerve; CT or MRI.
– Rule out other medical conditions that could pose
problems

Pre-implant Psychological Evaluation
– Assess for characteristics that might contribute to less
than optimal outcome.
The Implant Process
Implant surgery – general anesthesia
 Recovery/Healing – 4 – 5 weeks
 Activation, Fitting, and Mapping –






the child wears the processor
the processor is also attached to a computer
the clinic computer generates signals at carefully
controlled levels
the child is asked to indicate:
- the quietest signal heard (threshold level)
- the loudest comfortable signal heard (comfort
level)
these two levels are assessed for all the electrodes
in the cochlea (20 – 30 in all).
The Implant Process
– Using this information a speech processor
program is created which allocates sounds
between these two levels.
– The program mapping sets sounds so they are
loud enough to hear but not so loud as to be
uncomfortable.
– The program is fine-tuned during following clinic
sessions.
– This may occur a number of times during the
first year.

Auditory Training
 Speech and Language Training
Training is Everything
Typical Indications for Implants

Severe to profound sensorineural hearing loss
with poor speech recognition.
 Minimal or no benefit from the use of hearing aids
 Medically able to tolerate cochlear implant
surgery.
 Realistic understanding of the risks, benefits and
limitations of implantation
 Failure to develop good oral language skills
despite consistent hearing aid use and intensive
rehabilitative efforts
 A home and educational environment where oral
expression is encouraged and supported
The Pre-Implant Psychological
Evaluation

Knowledge Assessment
 Motivation for Implant
 Family Agreement/Disagreement
 Appropriateness of Expectations
 Challenges to Compliance
 Parent-Child Communication
 Family/Psychological/Behavioral
Issues
 Issues of Stress and Coping
 Questions/Concerns Regarding the
Implant Process
Knowledge Assessment

Do the parents (and child, if older) have reasonable
knowledge of what the implant process involves?
– What surgery will involve and the time necessary for
healing.
– The nature of post-implant activities (e.g., initial
fitting/activation and mapping, auditory training,
speech/language therapy, scheduled follow-ups).
– The need for parental involvement in the child’s therapy?
– What this will require in parental time and effort.
Have parents gone beyond “passive learning” in an
attempt to obtain information (e.g., internet
searches, making contacts with others who have been
implanted)?
 Any needed information?

Assessing Motivation for
Implantation

Do the parents (and child, if older) indicate a
desire for the implant?
 Have they been active in seeking information
regarding the implant?
 Have they been active in moving the implant
process along?
 Do they show a willingness to do “whatever
is necessary” to make the implant a success?
Family Agreement and
Disagreements

Do parent and child agree on the
desirability of the implant?
 Do both parents agree on the
desirability of an implant?
 Are both willing to be active
participants in the implant
process?
 Do other close family members
support the idea of an implant?
Assessing Expectations

Do parents and child (if old enough) convey an
understanding that children vary in response to
implants?
 Is there understanding that degree of success depends
on parent and child being active participants in the
process (e.g., auditory training, speech/language
therapy, etc)?
 Do they understand that the child may not “hear” the
same way as a non-hearing impaired individual?
 Is there implied acceptance of outcomes that may not
involve;
– the development of functional speech
– a full understanding of speech without speechreading?
Challenges to Compliance

Do parents/child convey a willingness to be an active
participant in the implant process?
 Do they have a plan to deal with practical issues
associated with implantation;
– arrangements for surgery,
– travel to doctor appointments,
– auditory training, speech therapy, etc.?

Is there a history of
– keeping appointments,
– active participation in prescribed communication
programs,
– complying with the use of assistive devices, and dealing
with other required medical treatments?
Assessing Stress and Coping

Is there evidence of significant family stress?
 What are the nature of existing stressors?
 Do family members have adequate social
supports to assist them in coping with ongoing
stressors?
 Do family members appear to have adequate
skills to cope with existing stressors?
 Considering both the level of stress and
coping styles, is stress likely to compromise a
successful outcome?
Assessing Other Psychosocial
Factors

Do parents appear to show evidence of deficits
that could compromise successful outcome or
require special assistance?
 Does the child show evidence of delays in
development severe enough to compromise
success?
 Do either parents or child show evidence of
psychological/behavioral problems that could
compromise success?
Psychological and Behavioral Issues:
Implications for Intervention

While not meant to be inclusive, listed below
are some common examples of psychological
and family issues, highlighted in the preimplant evaluation, that may warrant family
or behavioral intervention.
– Family Disagreement Regarding
Implantation
Parent-child differences
 Parent-parent differences

– Externalizing Disorders of Childhood
– Issues of Selective Noncompliance
Issues of Family Disagreement

Sometimes parents have markedly different views
regarding the desirability of an implant.
 In the case of older children or adolescents, parent
and child may have different views regarding the
implant decision making process.
 Such conflicts can potentially represent a significant
challenge to a successful outcome and may, in some
instances, represent a significant contraindication for
implantation.
 In other instances, family based interventions may be
recommended in an attempt to resolve issues prior to
implantation.
Case Examples
“Externalizing” Disorders

Psychological disorders that bring the child into
conflict with his/her environment can also pose
potential problems for children who are
implanted. These include problems like
ODD/CD.
“Externalizing” Disorders

Other childhood externalizing problems would
include problems such as ADHD
Issues with Externalizing
Behaviors Problems

The problem that severe child behavior disorders pose for
the child implant candidate are obvious.
 Children with ODD/CD may display defiant and noncompliant behavior to a degree that necessary auditory and
speech and language therapy is difficult if not impossible.
 Those with ADHD may be unable to benefit from their
training due their problems of impulsiveness,
inattentiveness and activity level.
 While displaying such problems may not represent an
absolute contraindication for implantation, it seems essential
that such problems be brought under control prior to
receiving an implant.
Issues of Selective
Noncompliance

In some instances the child does not display any
specific diagnosable disorder but does show evidence
of selective non-compliance.
 An example might be the child who refuses to wear
prescribed hearing aids despite the fact that he/she
derives some benefit from them.
 As this non-compliant behavior may be seen as
representing a challenge to implant compliance it may
be necessary for the child (and sometimes family) to
demonstrate compliance in this area prior to being
reconsidered for implantation.
Example
CI Evaluation: Overview

As can be seen from what has been presented here,
pre-implant psychological evaluations are quite
similar to evaluations conducted with child transplant
candidates.
 A major difference, being the absence of the major
medical stressors that are often associated with the
need for transplantation.
 While there are some instances where psychosocial
contraindications are so great that the child is denied
and implant, this is typically not the case.
 In the majority of cases the focus is on identifying
problems and addressing them so that implantation is
possible.
That’s All Folks!
Questions?