Ethics Rounds "Conclusion” Not Supported in the Literature

Donna L. Sorkin, Executive Director, American Cochlear Implant Alliance

Craig Buchman MD, Chair, American Cochlear Implant Alliance

Teresa Zwolan, PhD, Vice-Chair, American Cochlear Implant Alliance

Much of "Ethics Rounds: Should All Deaf Children Learn Sign Language” in the July 2015 issue of Pediatrics treats the decision on the use of sign language for a deaf child as unambiguous.  Although most of the authors embraced the use of sign in conjunction with a cochlear implant (CI), research on this topic is not definitive. The approach of most clinicians and educators who work in the field emphasizes spoken language unless the child has other complicating issues that require visual support. Notably, as Mellon and Niparko point out in their contribution to this discussion, spoken language outcomes with cochlear implantation are predicted by the level of spoken language proficiency that is achieved prior to implantation. Speech immersion is critical throughout the process. The Pediatrics panel’s "conclusion” that sign as a supplement to spoken language for deaf children is "clearly preferable” is not supported in the literature cited by Mellon and Niparko, nor in the wider literature, nor in practice, and points up bias in the stated conclusion.

American Cochlear Implant Alliance members are clinicians from across the care continuum  including surgeons, audiologists, therapists and educators working with children and families. Two factors have repeatedly been shown to affect language outcomes: (1) child’s age at the time of CI with the critical window being prior to 18 months of age (1,2,3) and (2) extent of enriching parental engagement with the child in learning and developing language (4).

Numerous dynamics that may affect the child’s development are ongoing. Parents must learn about use of technology and how to support a deaf child who is learning to listen and speak—the goal of most families choosing CI. Learning a second language, while a positive goal, may not be practical. Research shows that when a family is not fluent and ASL is given emphasis, the child’s language and reading levels fall behind because the family cannot provide the needed environment to foster an accelerated trajectory of language learning. For a child in a low SES family or single parent family or both, the burden of becoming fluent in sign can be overwhelming. The sign language decision is very personal and deserves thoughtful consideration with the CI team and family. There are no data supporting a single right approach.  

These issues are unlikely to fall within most pediatricians’ training. When advising families, pediatricians can and should emphasize two fundamentals that are supported by research—

·        early CI results in the best spoken language outcomes and,

·       family-centered intervention by personnel with specialized skills supporting spoken language development are indicated at an early age. 

A child with severe to profound hearing loss should be referred to a CI center by six months of age so that specialized clinicians can help the family to understand their options, including cochlear implantation. Too often families make their initial visit to a CI clinic after a child has lost valuable time, after the critical neurobiological window of opportunity to optimize auditory language outcomes has closed.

References

1. Niparko JK, Tobey EA, Thal DJ, Eisenberg LS, Wang NY, Quittner AL, Fink NE. Spoken language development in children following cochlear implantation. Childhood Development After Cochlear Implantation. Investigative Team, JAMA 2010 April 21; 303(15):1498-506.

2. Svirsky MA, Teoh SW, Neuburger H. Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol Neurotol. 2004 Jul-Aug;9(4):224-33.

3. Geers AE, Nicholas JG. Enduring advantages of early cochlear implantation for spoken language development. J Speech Lang Hear Res. 2013 Apr;56(2):643-55. doi: 10.1044/1092-4388(2012/11-0347).

4. Quittner AL, Cruz I, Barker DH, Tobey E, Eisenberg LS, Niparko JK. Effects of maternal sensitivity and cognitive and linguistic stimulation on cochlear implant language development over four years. Childhood Development After Cochlear Implantation Investigative Team. J Pediatr, 2013 Feb:162(2):343-8.e3