Position Paper: Pediatric Habilitation Following Cochlear Implantation
ABOUT US
The American Cochlear Implant Alliance (ACI Alliance) is a non-profit, 501(c)3 whose mission is to advance the gift of hearing by cochlear implantable prosthetic hearing implants through research, advocacy and awareness. The membership includes those who provide intervention (e.g., ENT surgeons, audiologists, speech-language pathologists), other professionals on implant teams (e.g., educators, psychologists, researchers), parents of children with cochlear implants, and other advocates. For more information: www.acialliance.org.
This document defines appropriate speech/language habilitation services for children following cochlear implantation. It provides a rationale based upon state-of-the-art research and clinical findings. Speech-language habilitation for children after cochlear implantation falls under the definition of "habilitative services” crafted in 2010 by the National Association of Insurance Commissioners. It defines habilitation, in part, as:
"Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age."
RATIONALE
Recommendations are not based upon a single factor; but rather on evidence from five domains of knowledge and practice that reinforce one another and provide a compelling rationale. These are:
1. Independent research studies of children with cochlear implants have documented that, on average, these children receive one to two (1)-hour speech/language habilitation sessions per week (Dettman et al., 2013; Dornan et al., 2010; Rhoades, 2001). These findings apply to children who develop spoken language in synchrony with their hearing peers as well as those who demonstrate "catch up” growth. Domain: Clinical Outcomes Research
2. When a child with hearing loss demonstrates a delay in spoken language relative to his/her chronological age, the amount of habilitation time needed to close the gap is directly proportional to the delay. In other words, if a child receives amplification at 18 months, clinical experience suggests that it takes about three years of habilitation to achieve speech and language skills equivalent to a hearing peer (Flexer and Richards, 1998). Domain: Clinical Management Reports
3. Deafness causes a child’s brain to re-organize in the absence of consistent auditory input. Without sound, areas of the brain designated as auditory centers are assigned to other sensory modalities, such as vision or touch. After stimulation of the auditory cortex of the brain via cochlear implants, there is urgency in providing rich and consistent auditory-based habilitation. Only limited time is available within the sensitive period of cortical development to intervene with habilitation (Gordon et.al.,2011; Kral, 2013; 2011; Sharma, Nash, & Dorman, 2009; Sharma & Campbell, 2011). Domain: Neuroplasticity Research
4. To achieve maximum benefit from cochlear implants, children need ongoing, consistent habilitation, rather than episodic services occurring as a result of a limited number of sessions allowed in a given benefit year. Experts in pediatric communication endorse the notion that professionals must use evidence and clinical decision making to individualize recommendations for each child (Bailes, Reder, & Burch, 2008). Major changes occur in children’s communication skills over a period of four years—the last 2 years involve the most "catch up growth” (Lin, Niparko, & Francis 2009.). Domain: Habilitation Best Practices
5. When analyzed over a lifetime, children who are denied the benefits of cochlear implantation have demonstrated a dramatically disproportionate shortfall in quality of life relative to other disease states (Lindemark, Norheim, & Johansson, 2014). The negative economic impact of lifelong hearing loss, referred to as "societal cost of deafness,” is reduced dramatically when interventions such as cochlear implants and appropriate follow-up habilitation are provided (Mohr et al., 2000; Lin, Niparko & Francis, 2009). The savings to society may be as high as one million dollars over the lifetime of an individual born with severe/profound hearing loss (Mohr etal., 2000). Domain: Health Economics Research
RECOMMENDED HABILITATION STANDARD
Based upon the published evidence reviewed above, 50 to 100 (1) hour speech/language habilitation sessions are recommended per year for pediatric cochlear implant users. Helping a child learn to understand and utilize the hearing benefit provided by a cochlear implant is a complex process that requires expertise and specialized training. Because of this, speech/language habilitation should be provided by a professional who is knowledgeable about the hearing and listening needs of the child with a cochlear implant. In order to obtain optimal outcomes, such habilitation typically involves provision of service and coordination by all professionals involved in a child’s care. As each child is unique, health care providers will make individual recommendations as part of their management of the child. Some children may require fewer habilitation sessions, while others may require more.
REFERENCES
Bailes, A.F., Reder. R., & Burch. C. (2008). Development of guidelines for determining frequency of therapy services in a pediatric medical setting. Pediatric Physical Therapy. Summer; 20(2): 194-8.
Dornan D., Hickson, L, Murdoch, B., Houston, K.T. & Constantinescu, G. (2010). Is auditory-verbal therapy effective for children with hearing loss? Volta Review, 110 (3),361-387.
Dettman, S., Wall, E., Constantinescu, G., & Dowell, R. (2013). Communication outcomes for groups of children enrolled inauditory-verbal, aural-oral and bilingual-bicultural early intervention programs. Otology & Neurotology, 34, 451-459.
Flexer, C, & Richards, C. (1998). We can hear and speak! The power of auditory-verbal communication for children who are deaf orhard of hearing. Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing.
Glossary of Health Insurance and Medical Terms. http://www.naic.org/documents/committees_b_consumer_information_ppaca_glossary.pdf
Gordon, K., Wong. D., Valero, J., Jewell, S., Yoo, P. & Papsin, B. (2011).Use it or lose it? Lessons learned from the developing brains of children who are deaf and use cochlear implants to hear. Brain Topography 24 (3-4), 204-219.
Kral, A. (2013). Auditory critical periods. A review from system’s perspective. Neuroscience. 247, 117-133.
Lin, L.M., Niparko, J.K., & Francis, H.W. (2009). Outcomes in cochlear implantation assessment of quality of life impact and economic evaluation of the benefits of the CI in relation to costs. In Niparko, Kirk, & Robbins (Eds.), Cochlear implants principles and practices, (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Lindemark, F., Norheim, O.F., & Johansson, K.A. (2014). Making use of equity sensitive QALYs: A case study on identifying the worse off across diseases. Cost Effectiveness and Resource Allocation 2014, 12:16
Mohr, P.E., Feldman, J.J., Dunbar J.L., Niparko, J.K., Robbins, A.M., Rittenhouse, R.K., & Skinner, M.W. (2000). The societal cost of severe to profound hearing loss in the United States. International Journal of Technology Assessment in Health Care, 16 (4),1120-1135.
Niparko, J. (Ed.). (2009). Cochlear implants: Principles and practices, (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Rhoades, E.A. (2001). Language progress with an auditory-verbal approach for young children with hearing loss. International Pediatrics, 16(1), 1-7.
Sharma, A., & Campbell, J. (2011). A sensitive period for cochlear implantation in deaf children. Journal of Maternal, Fetal. Neonatal Medicine, 24 (Suppl 1), 151-153.Sharma A., Nash, A. A., & Dorman, M. (2009). Cortical development, plasticity, and re-organization in children with cochlear implants. Journal of Communication Disorders 42 (4), 272-9.
Authored by: Hannah R. Eskridge, MSP, CCC-SLP, LSLS Cert. AVT, Amy McConkey Robbins, MS, CCC-SLP, LSLS Cert. AVT, Kathryn Wilson, MA, CCC-SLP, LSLS Cert. AVT, Lindsay Zombek, MS, CCC-SLP, LSLS Cert. AVT
Approved by the Board of Directors, American Cochlear Implant Alliance, July 27, 2015
© 2015 American Cochlear Implant Alliance
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