Cochlear Implants: Fundamentals and Application - part 10 potx

The benefits of cochlear implants in developing language have been rized by Spencer 2002 as follows: “Cochlear implants provide many, but notall, deaf children with access to information

Speech Production with Cochlear Implants 745

strategy on Nucleus 22 implant were reported by Tobey et al (1988, 1991) andTobey and Hasenstab (1991) The speech production of children was categorizedfrom the phonologic level evaluation (Ling 1976) Of the 61 children in the study,31% had a significant improvement in imitative nonsegmental speech production,and 67% in segmental speech production 1 year after implantation (Tobey et al

1988, 1991; Tobey and Hasenstab 1991) Approximately half had significant provement in spontaneous speech production The data suggested that childrenwith increased auditory experience before implantation also developed betterspeech It was subsequently shown by Tye-Murray et al (1995) that there wasimproved intelligibility in children who had used the Nucleus 22 system for 2years or longer, and in those who had been implanted before the age of 5 years

im-Multipeak-MSP (Nucleus)

As with the formant strategies, there was also considerable variability in mance Osberger et al (1994) found speech intelligibility scores of 48% for chil-dren who had the Nucleus F0/F1/F2 WSP-III and Multipeak-MSP systems for atleast 2 years This score was well below that for hearing children of the sameage The ratings varied from 14% to 93% intelligible Thus some children perform

perfor-as well perfor-as hearing children

Over a 6-year period Blamey et al (2001a) assessed the progress in speechproduction of nine children with the Nucleus 22 system Initially, two used theF0/F1/F2 strategy and seven the Multipeak At 3 years postimplantation all wereusing the Multipeak, and by 6 years they had been converted to SPEAK A broadtranscription of the conversations was used to measure the percentage of correctproductions of monophthongs, diphthongs, singleton consonants, consonant clus-ters, and whole words A direct measure of intelligibility was also derived bycounting the proportion of syllables that were unintelligible to the transcribers.The conversation was transcribed by a speech pathologist or linguist and analyzed

by CASALA Four years postimplantation, at least 90% of all syllables producedwere intelligible (Fig 12.5), although only one child had intelligibility over 19%prior to implantation

SPEAK and ACE Spectra-22 and Nucleus 24

Studies are required to follow the speech production of young children implanted

at a young age with the Nucleus 24 device with the SPEAK and ACE strategies.The development of speech production in children who used a tonal languagesuch as Cantonese has been assessed by Barry et al (2000) for the SPEAK strategy

It was thought the children with SPEAK should acquire a tonal inventory morerapidly than one for vowels (the latter depending on formants) But a study onthree children by Barry et al (2000) showed that the acquisition of a tonal speechinventory was slower, with none acquiring a low-falling element This could havebeen due to the fact that that the extraction of voicing as rate of stimulation withthe Nucleus Multipeak and other formant strategies provides better pitch percep-tion and requires investigation Ciocca et al (2002) found in 17 children, in whom

six used SPEAK and 11 ACE, that above-chance performance was obtained withthree tonal contrasts but was poorer than a moderately impaired control Thissuggests that the strategy is not providing the fine temporospatial patterns requiredfor comparable hearing.

Comparison with Hearing Aid and Tactile Vocoder

It was also an important question to compare the speech production benefits fromthe F0/F1/F2 strategy on the Nucleus 22 implant with those from the 3M/Housesingle channel and Tactaid II (two-channel vibrotactile aid) The speech was clas-sified as nonspeech, speech-like, and speech The largest improvements were forthe Nucleus 22 (F0/F1/F2) speech strategy But only 67% of their utterances werejudged to be phonetic approximations (Osberger et al 1991b) After 1 year thechildren with the Nucleus 22 (F0/F1/F2) speech strategies showed an increase inthe number of stops, fricatives, and glides, and a reduction in nasal consonants.Osberger et al (1991c) compared the speech of children with the Nucleus 22 (F0/F1/F2) speech strategies and children with hearing aids and different hearingthresholds After 4 years the mean intelligibility of the children with the Nucleus

22 (F0/F1/F2 and Multipeak) speech strategies was 40% compared with 20% forthe aided children with thresholds of 101 to 110 dB The intelligibility did notreach those children with a threshold of 90 to 100 dB when using a hearing aid

In a comparative study by Tobey et al (1994), triads of children with the cleus 22 implant, hearing aids, and the Tactaid II and IV were compared Theywere matched for age, unaided thresholds, family support, intelligence, and

Nu-Language Development for Pre- and Postlinguistically Deaf Children 747

speech and language skills After 3 years the children with the Nucleus implanthad increases in imitative speech production of 36% compared to 20% for boththe hearing aid and Tactaid groups

Svirsky et al (1998) compared the speech intelligibility of 44 children usingthe Nucleus SPEAK and Clarion CIS strategies, and after 1.5 to 2.5 years’ usagethe speech of the implant children was the same as for those with a threshold inthe 90- to 100-dB range

Language Development for Pre- and Postlinguistically

Deaf Children

The development of receptive and spoken language by deaf children is very portant for their education, social development, and career opportunities This cannow be achieved through early diagnosis with procedures that include steady-state evoked potentials (Rickards and Clark 1984; Cohen et al 1991; Rance et al

im-1993, 1995), auditory brainstem responses (ABRs) with a “notched-noise” masker(Stapells et al 1995), and otoacoustic emissions (Kemp 1978), as well as withearly intervention and training programs (Ling 1976, 1984; Ling and Ling 1978;Ling and Nienhuys 1983) The elements of spoken language as discussed above(see Language: Test Principles) are (1) receptive and expressive; (2) cognitive,motor, and sensory; and (3) phonology, morphology, syntax, and pragmatics.The language of children with a cochlear implant is related to their speechperception Cochlear implants provide information in the middle to high speechfrequency range not available to the children, as they usually have only low-frequency hearing Their speech perception can be predicted to a reasonable de-gree, as discussed in some detail above (see Predictive Factors) and in Chapters

9 and 11, and thus their language ability can also be predicted In developinglanguage it is important to consider the nature of the child, family, and habilitation

or education programs (Spencer 2002)

The benefits of cochlear implants in developing language have been rized by Spencer (2002) as follows: “Cochlear implants provide many, but notall, deaf children with access to information that can help them develop under-standing and production of spoken language However, the range of benefits ex-perienced is large and the factors that influence the benefits received by an indi-vidual child are still being investigated.”

summa-Receptive Language

There is a normal distribution of equivalent language age for children with goodhearing, as for example measured with the CELF test Children with a hearingloss and a hearing aid or a cochlear implant have language that falls predominantlyoutside this distribution (Blamey 2002) Studies on hearing-impaired childrenindicated that extrinsic factors leading to language delays are age of intervention(Davis et al 1986; Ramkalawan and Davis 1992; Gilbertson and Kamhi 1995;

748 12 Results

Limbrick et al 1992; Dodd et al 1998; Yoshinaga-Itano et al 1998) and time spentreading (Limbrick et al 1992) Intrinsic factors are specific language impairmentseen in 10 of 20 (50%) of hearing-impaired children by Gilbertson and Kamhi(1995) and speech-reading ability (Dodd et al 1998) It is important to distinguishbetween these extrinsic and intrinsic factors Initial studies on small groups ofchildren showed receptive language improved with the Nucleus 22 (F0/F1/F2 andMultipeak) (Kirk and Hill-Brown 1985; Busby et al 1989; Dowell et al 1991;Geers and Moog 1991; Hasenstab and Tobey 1991) This trend was confirmed

by Dawson et al (1995a,b) from the data on a larger group of 32 children Onaverage they had a language-learning rate of 0.87 based on the PPVT that wasapproximately double the 0.4 to 0.6 rate for children with hearing aids (Geersand Moog 1988; Boothroyd 1991b)

Comparing the learning rates for the implant and hearing aid groups madeallowance for maturation by assuming it was the same for both To further isolatematuration, Robbins et al (1995, 1997) predicted the effects on the Reynell scale(Reynell and Gruber 1990), and found that for the Nucleus 22 implant the lan-guage increase was 7 to 10 months ahead of expected after 12 to 15 months.The factors responsible for differences in receptive language were examined

by Dawson et al (1995a,b) They first confirmed the findings of Osberger et al(1991a), Staller (1990), and Staller et al (1991a,b) for the Nucleus 22 system thatage at onset of deafness and duration of the profound hearing loss correlatednegatively with speech perception Second, the variance among children for thegrowth of vocabulary was not significantly accounted for by these factors as well

as duration of use, perception performance, and communication mode A laterstudy by Connor et al (2000) found a receptive vocabulary growth of 0.63 forchildren implanted at 2 years compared to 0.45 for children implanted at age 6.5years

It was also necessary to monitor language acquisition over time to determinethe longer term effects of the Nucleus 22 multiple-channel cochlear implant andF0/F1/F2 and Multipeak strategies Sarant et al (1996, 2001) and Blamey et al(1998) studied 57 children aged between 4 and 12 years with a bilateral severe

or profound hearing loss over a 4-year period There were 33 hearing aid and 24implant users Receptive language measured with the PPVT was on average 62%

of the expected level for hearing children There were considerable differences

in performance, and some were at the normal level The results for children withimplants were comparable to those for children with hearing who had a meanthreshold of 81 dB

The structural complexity of language as well as vocabulary developed onaverage faster than predicted for deaf children without cochlear implants Thiswas assessed with the RDLS test (Svirsky et al 2000) Nevertheless, after 18months some of the 23 children in the study continued to have severely delayedexpressive language compared to children with unimpaired hearing Some, how-ever, progressed at a rate typical for hearing children Bollard et al (1999) alsoreported scores on vocabulary and language comprehension in 10 young childrenthat increased at a rate equal to or faster than hearing children at an equivalent

Language Development for Pre- and Postlinguistically Deaf Children 749

FIGURE12.6 Speech perception (Bamford-Kowal-Bench (BKB) words in sentences) withaudition and speech reading versus Peabody Picture Vocabulary Test (PPVT) equivalentlanguage age for implanted and aided children (Sarant et al 1996, 2001; Blamey et al1998) (Reprinted with permission from Blamey et al 1998 Speech perception and spokenlanguage in children with impaired hearing In: Mannell, R H and J Robert-Ribes, eds.ICSLP ’98 Proceedings: 2615–2618.)

language level Nevertheless, after 18 months their language was behind the samechildren with hearing

The above studies showed considerable variability in receptive language, and

in general children were not reaching age-appropriate language The data cated the variability did not depend only on percepts such as place pitch percep-tion (Busby and Clark 2000a,b) or the general factors leading to good speechperception (Dawson et al 1995a,b) A study was therefore undertaken to evaluatehow strong a relationship existed between speech perception and language Thespeech perception word and sentence scores for audition (A), speech reading (V),and audition plus speech reading (AV) were plotted against the PPVT or CELFequivalent language As discussed in Chapter 11, a very close relationship wasseen The AV word score reached 100% at a PPVT or CELF age of approximately

indi-8 to 10 years and the A score at 10 to 11 years (Fig 12.6)

So although language age did not increase at quite the same rate as for normalchildren, it rose rapidly in proportion to speech perception in quiet However, itwas not clear to what extent perception and language were interdependent

It was hypothesized that open-set speech perception was limited by vocabularyand that remediation of vocabulary and syntax would increase open-set speechperception scores A study was undertaken on three implanted children from 9 to

15 years of age (Sarant et al 1996) The perception scores were recorded forwords that were both known and unknown They were retested after the meanings

of all words had been learned Two of the children had statistically significantimprovements in the unknown word scores rather than for the known words,suggesting that it was not a practice effect but due to the effect of “top-down”

750 12 Results

processing on “bottom-up” perception The BKB sentence test was then used toassess specific grammatical constructs, again after the children had been taughtthe rules governing their use There was benefit for two of the three children.Improvements in receptive language as reported above for the Nucleus 22 F0/F1/F2 and Multipeak strategies are also being seen for the Clarion CIS strategy,which was approved by the FDA in 1997 In a study on 23 young children, theywere found to have a greater than normal increase in language (Robbins et al 1991)

Expressive Language

The expressive language of children, as discussed above, can be analyzed at aphonological level using articulation tests and phonetic transcripts of spoken lan-guage The results are presented as phonetic inventories, percent correct pho-nemes, or phonological processes The order of occurrence of the phonemes isthought due to linguistic, acoustic, and articulatory factors It was shown by Bla-mey et al (2001b) in a study on nine children using the Nucleus multiple-channelcochlear implant that the order of development was the same as for children withunimpaired hearing, although delayed

In addition, conversational speech samples were analyzed from nine childrenwho received the Nucleus 22 implant and F0/F1/F2 and Multipeak speech-pro-cessing strategies between the ages of 2 and 5 years (Blamey et al 2001a) Therewas a significant increase in the complexity of the spoken language of the im-planted children seen in the study by Blamey et al (2001a) The mean number ofsyllables both intelligible and unintelligible rose from 1.7 to 5.2

The PPVT can be used to evaluate expressive language with the expressivesubtest of the Woodcock Johnson Tests of Cognitive Ability Woodcock andMather (1989) and Blamey et al (2001c) found using the test that the implant andhearing aid users progressed at about 65% of the normal rate This was similar

to the rate for receptive language in children implanted at age 2 years A markedimprovement in language with implant children was reported by Svirsky et al(2000), who found the rate of language development was comparable to that ofchildren with unimpaired hearing

The production of English grammar for 57 children implanted between 4 and

12 years of age and who used the Nucleus 22 F0/F1/F2 and Multipeak systemswas measured with the CELF-3 and CELF-Preschool tests (Blamey et al 1998).The results were on average 45% of the expected level The development ofgrammar skills in 29 children in a total communication (simultaneous speech andsigned language) program using the Nucleus 22 F0/F1/F2 and Multipeak speech-processing strategies or hearing aids was studied by Tomblin et al (1999) Thechildren’s ability to use expressive grammar (syntax) in this study was measuredwith story retelling A control group of unimplanted deaf children was involved

in the study The children were 3 to 13 years postimplantation The children’sunderstanding of sentence structure was assessed by their performance on theRhode Island Test of Language Structure The sentences were presented in speechplus signed English The results showed that all but one of the children with the

Language Development for Pre- and Postlinguistically Deaf Children 751

Nucleus 22 cochlear implants scored very high, and well above the expectedresults for deaf children The scores improved from 30% to 65% in the first 5years of cochlear implant use, while children with unimpaired hearing improvedfrom 30% to 90% between the ages of 2 and 4 years In addition, the childrenwith implants tended to use speech (without signs) for a larger percentage of theirwords than did deaf children without implants, although both groups continued

to use both modalities simultaneously for the majority of their productions.Grammatical morphemes are difficult for deaf children to recognize and pro-duce Spencer et al (1998) found that 25 children with cochlear implants usedgrammatical morphemes more often than 13 children with hearing aids in a totalcommunication program The children with implants did not use signs for ex-pressing these morphemes, although speech and signs were used together for themajority of other words This indicated the children with implants could perceivethe morphemes and incorporate them into their expressive language Furthermore,despite the language delays, they integrated the morphemes into their language

in the same order as hearing children

Cognition

As discussed above, there were considerable differences in the speech perception,speech production, and language results for children with the multiple-channelcochlear implant, and only about one third to one half of the variance of thespeech perception scores could be accounted for (Dowell et al 1995; Sarant et al2001) Furthermore, the receptive language scores did not match those for normal-hearing children (Blamey et al 1998; Sarant et al 2001) For the above reasons,cognitive studies were commenced to help determine the factors that contribute

to the development of language Cognition involves perception, attention, ing, and memory Information processing theory emphasizes that these processesshould be viewed as a continuum and that all involve some kind of storage system

learn-or memlearn-ory (Pisoni 2000) The effect of restlearn-oring some hearing with a channel cochlear implant on visual attention was first studied, as deaf childrenhad been shown to have deficits in visual matching tasks (Moores et al 1973).Deaf children with cochlear implants performed better than those without, andalso developed visual selective attention at a faster rate (Quittner et al 1994) But

multiple-in another study no substantial difference was found between children with ing, prelinguistically deaf without a cochlear implant, and deaf with a cochlearimplant on a continuous performance visual attention task and a letter cancellationtask

hear-A study was undertaken by Surowiecki et al (2002) to compare matchedchildren with either hearing aids or cochlear implants with eight neuropsycho-logical measures of visual memory, attention, and executive functioning It alsoexamined whether differences in cognitive skills could account for variance inspeech perception, vocabulary, and language abilities First, there was no differ-ence between the cognitive abilities of the aided and implanted children Second,the children’s visual memory skills (i.e., recognition memory, delayed recall, and

752 12 Results

paired associative learning memory) correlated with their language, but attentionand executive functioning did not Further research is needed to determine howthe development of language with a cochlear implant can be assisted

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Wiig, E., W A Secord and E Semel 1992 Clinical evaluation of language tals—preschool San Antonio, TX, Psychological Corporation, Harcourt Brace.Wilson, B S 2000 Strategies for representing speech information with cochlear implants.In: Niparko, J K., ed Cochlear implants: principles and practice Philadelphia, Lippin-cott Williams & Wilkins

fundamen-Wilson, B S., D T Lawson, M Zerbi and C C Finley 1992 Speech processors forauditory prostheses Twelfth quarterly progress report, April 1992 NIH contract N01-DC-9-2401 Research Triangle Institute

Wilson, B S., D T Lawson, M Zerbi and C C Finley 1993 Speech processors forauditory prostheses Fifth quarterly progress report, Oct 1993 NIH contract N01-DC-2-2401 Research Triangle Institute

Woodcock, R W and N Mather 1989 Woodcock-Johnson tests of cognitive ability Allen,

TX, DLM Teaching Resources

Xu, S., R C Dowell and G M Clark 1987 Results for Chinese and English in a tichannel cochlear implant patient Annals of Otology, Rhinology and Laryngology96(suppl 128): 126–127

mul-Yoshinaga-Itano, C., A L Sedey, D K Coulter and A L Mehl 1998 Language of and later-identified children with hearing loss Pediatrics 102: 1161–1171

early-Zimmerman, I L., V C Steiner and R E Pond 1979 Preschool language scale ombus, Merrill

Col-Zimmerman-Phillips, S., A M Robbins and M J Osberger 2000 Assessing cochlearimplant benefit in very young children Annals of Otology, Rhinology and Laryngology109(suppl 185): 42–43

13

Socioeconomics and Ethics

The speech and language results of cochlear implants as well as their biologicalsafety are crucial in assessing the socioeconomic benefits and ethics of theprocedure

Speech and Language Benefits

The speech perception, speech production, and language results were discussed

in detail in Chapter 12 and the biological safety in Chapters 3 and 4 The speechand language benefits of the Nucleus 22 F0/F2 WSP-II, F0/F1/F2 WSP-III, Mul-tipeak-MSP, SPEAK Spectra-22 systems, the Nucleus 24 SPEAK, CIS, and ACEsystems, and the Clarion and Combi-40 CIS systems were demonstrated on adultsand children by Staller et al (1991), Miyamoto et al (1992), Blamey et al (1992),Dawson et al (1992, 1995), Tobey and Hasenstab (1991), Geers and Moog (1994),Cowan et al (1995), Dowell et al (1995), Kirk et al (1995b), Tye-Murray et al(1995), and others This was acknowledged by the National Institutes of Health(NIH) Consensus Statement on Cochlear Implants in Adults and Children (1995),which said “implantation in conjunction with education and habilitation leads toadvances in oral language acquisition.”

Biological Safety

The toxicity of the materials used with the first Nucleus cochlear implant wereevaluated at the University of Melbourne from 1980 to 1982 The research wasundertaken according to the good laboratory practice requirements of the U.S.Food and Drug Administration (FDA) for its premarket approval (PMA) Addi-tional tests for cytotoxicity were carried out by an independent laboratory Thestandards were developed from recommendations of the American Society forTesting Materials (ASTM), subsequently outlined in the Animal Book of ASTMStandards (1986) Other research on the effects of trauma and infection on the

768 13 Socioeconomics and Ethics

cochlea were also studied intensively by the Department of Otolaryngology atthe University of Melbourne for the FDA

Before implanting infants and young children, further biological safety studieswere required The NIH contract to the University of Melbourne for studies onpediatric auditory prosthesis implants, NIH contract No 1-NS-7-2342, from 1987

to 1992, resulted in findings that there was no higher incidence of middle earinfection leading to labyrinthitis than in unimplanted ears, provided the electrodeentry point was grafted with fascia; that head growth had no adverse effects onthe implant, and vice versa; and that electrical stimulation had no deleteriouseffects on an immature nervous system This was discussed in the bioengineeringsection in Chapter 8, as well as Chapters 3 and 10

Social Benefits

Adequate hearing and the development of aural speech and language in childrenare essential for communicating in the hearing community A severe-to-profoundhearing loss in early life limits children’s proper acquisition of oral and writtenlanguage, which places great limitations on their education and career opportu-nities (Bamford and Saunders 1991) When it occurs in adults, it can have amarked effect on their ability to continue in a job or to relate to family and friends.There are also marked advantages in hearing environmental sounds in the social,school, or work setting For the above reasons, the restoration of the ability tohear in adults and the development of speech perception and production as well

as receptive and expressive language in children with a cochlear implant are ofgreat importance

Personal

Even single-channel implants made a significant difference to the quality of aperson’s life In a questionnaire (Fraser 1987), the patients’ expectations of hear-ing environmental sound were met in more cases than their expectations of thesingle-channel device as an aid to speech reading However, more than half ofthe adults gave hearing any sound and relief from isolation as their primary rea-sons for wanting an implant, and to this extent the implant too had been suc-cessful All patients reported an improvement in their quality of life

Family

The ultimate benefits of successful cochlear implantation for the family are what different for postlinguistically deaf adults compared to pre- and postlin-guistically deaf children For the adult it may be the ability to get a job or takemore responsibility in the workplace, to have more effective communication withhis/her spouse and thus a more fulfilled marriage, and/or to have a more activerole as a parent or grandparent in the family

some-Economic Benefits 769

For children, cochlear implantation should lead to a normalizing effect on lations with siblings, and a more equal sharing of time commitments from theparents for each child However, with implanted children it must be realized thatthe initial intensive period of (re)habilitation can be stressful (Downs 1986; Quitt-ner et al 1991) as is coping with slow language development (Evans et al 1989).The additional time required for training, and the distances to be traveled to theclinic also are likely to strain family relations Assistance from grandparents andcontact with other families at this time can be especially useful (Cowan 1997)

a hearing loss (HL) of 106 dB HL and using cochlear implants obtained speechperception and receptive and expressive language at a level comparable to chil-dren with a hearing loss of about 78 dB HL This was presumed due to the betterspeech processing strategy with SPEAK

The speech production of children with the Nucleus (F0/F1/F2) processor proved to 31% with imitative nonsegmental speech production, and 67% withsegmental speech production 1 year after implantation (Tobey et al 1988, 1991;Tobey and Hasenstab 1991) Approximately half had significant improvements

im-in spontaneous speech production

For receptive language measured with the Rhode Island Test of LanguageStructure, the results showed that all but one of the children with the earlierNucleus cochlear implants scored very high, and well above the expected resultsfor deaf children (Tomblin et al 1999) Expressive language when measured forgrammar also showed the implanted children performed significantly better than

a control group of unimplanted children (Tomblin et al 1999) These and otherimprovements, discussed in Chapter 12, have meant that many implanted childrencan be educated in a mainstream school, both with and without a special unit(Nevins and Chute 1995)

Economic Benefits

Economic Measures

The economic benefits can be assessed in terms of (1) cost-effectiveness analysis,which measures the outcomes in natural units; (2) cost-benefit analysis, which

770 13 Socioeconomics and Ethics

measures the benefits in monetary terms; and (3) cost-utility analysis, which sures the outcomes in years of healthy life or quality-adjusted life-years (QALY)gain (Evans et al 1995) These measures are required for comparing medicalprocedures, especially when seeking government resources and funds Thus thebenefits should not only improve the quality of life, but also remove the need foralternative management and increase patients’ productivity in society Their in-creased productivity may result from an ability to resume their previous occu-pation or achieve promotion (Cowan 1997)

mea-Cost-Effectiveness

Cost-effectiveness can be measured quantitatively, for example, the number ofproductive life-years added or days of disability saved The cost-effectiveness isrelated to the degree of benefit from the device, although this has not been quan-tified Cochlear implant speech perception, speech production, and languagescores can also be compared with those obtained preoperatively using hearingaids or other sensory devices The studies by Flynn et al (1996a,b, 1997, 1998a,b)have shown that for postlinguistically deaf adults the results with cochlear im-plants are comparable to those for people with a severe hearing loss of 78 dB HLusing a hearing aid Studies by Osberger et al (1993), Geers and Moog (1994),and Kirk et al (1995a) suggest that the direct benefits available to individualsfrom use of cochlear implants were significantly higher than those from eitherhearing aids or tactile devices A comparison of the productivity of people withdifferent degrees of hearing loss could help quantify the cost-effective benefits of

a cochlear implant Although the cochlear implant device is more expensive thanthe other aids, the long-term savings to the community in job performance andeducation costs are critical

Cost-Benefit Analysis

The cost-benefit analysis measures the savings from adults’ greater productivityand from children’s not needing to attend special kindergartens and schools oruse other services With implanted children, there are significant savings to thesociety because many implanted children can attend mainstream school, ratherthan being educated in a special segregated school for hearing-impaired childrenthat has higher costs due to lower teacher–student ratios Figure 13.1 illustratesthe 12-year costs in the state of Victoria, Australia, for educating children inmainstream schools, mainstream schools with a special unit, and special schools.The net savings for each child receiving a cochlear implant can be derived bysubtracting the cost of the implant procedure from the savings from educatingthat child in a mainstream school The savings to the community can then becalculated from the proportion of children having cochlear implants and the pro-portion of those children able to be educated in mainstream schools

In the United States, Nevins and Chute (1995) reported the growing trend forchildren using cochlear implants to move from special self-contained facilities to

Economic Benefits 771

$350,000

Special School for the Deaf

SpecialUnit

Mainstream schooling

Minimal or nospecial support

24%

44%

32%

17% 23%

60% 1999

more mainstream settings Wyatt et al (1996) estimated savings of $152,000 ineducational costs for each child implanted by age 4 years, assuming 50% weremainstreamed at 3 years postimplantation, and 90% partially mainstreamed by 6years postimplantation

Quality of Life

Since hearing loss is not generally a life-threatening disability, the cochlear plant procedure itself has little direct impact on life expectancy However, co-chlear implantation does improve the patient’s quality of life, through restoring

im-or allowing acquisition of auditim-ory skills, improving articulation, and enhancingthe development of language comprehension, including reading and writing skills

in children Indirect benefits flowing from improved communication in implant

772 13 Socioeconomics and Ethics

patients are a major contributor to the improvement in quality of life (Lea 1991).Because it allows assessment of the impact of both direct and indirect benefits,cost-utility analysis has advantages in the economic evaluation of cochlear im-plants in adults and children (Cowan 1997) Improved quality of life is measured

in relation to the cost of the intervention

The cost-utility analysis measures the cost to achieve outcomes in years ofhealthy life or QALY gain In calculating the QALY, the x-axis measures theduration of life in years from birth to death, and the y-axis indicates the level ofhealth-related quality of life on a scale from 0 to 1, in which 0 indicates deathand 1 indicates perfect health This index must be standardized to allow compar-ison of diverse types of treatments The area that is added in improved qualityand length of life from the medical intervention is measured in QALYs A treat-ment that prolongs the life of the patient represents a significant increase in QALY(a value of 1.0) In contrast, a treatment that improves patients’ general healthand ability to resume their normal life is represented as a proportional increase

in QALY (a value between 0.1 and 0.9) The QALY quantifies both the prevention

of morbidity, or life improvement, and the duration over which this is maintained.The cost per QALY can be calculated through establishing all relevant costs

of the treatment, and this monetary figure provides a measure of the value of thetreatment to the individual and the economic costs and impact on the healthauthority or society in general The costs of a cochlear implant program need tocover all expenses, including the audiological and otological consultations andspecial investigations The cost-utility analysis can be calculated as a ratio of thecosts of a specific medical treatment or intervention, and the value of the outcomes

in QALYs

As emphasized by Evans et al (1995), the key is the quality scale increaseapplicable to the typical cochlear implant recipient The Ontario Health UtilitiesIndex (OHUI) is a commonly used multiattribute health status system for mea-suring the quality scale The OHUI considers the effects of treatment on sevenquality of life categories: sensory, emotion, cognitive, mobility, self-care, pain,and fertility In the Battelle study (Evans et al 1995), although the cochlear implanthas a positive influence on three OHUI categories, sensory, emotion, and cogni-tion, only the sensory category was considered It was then assumed a change toopen-set speech understanding caused the recipient to move from level 4 (blind,deaf, or mute) to level 3 (sees, hears, or speaks with limitations, even with equip-ment) This represented 0.27 on the scale from 0 to 1, or a 27% increase in lifequality Battelle then assumed that only 67% of cochlear implant recipientsreached open-set ability, which then translated to a general 0.18 change on theOHUI scale

Based on an estimate of costs for the intervention, and the expected length ofdevice use, the typical cochlear implant recipient would achieve a cost-utilityratio of $15,590 per QALY As a comparison, the cost-utility ratios for otheraccepted medical interventions in dollars per QALY were neonatal intensive care,

$7970; coronary angioplasty, $11,490; implantable defibrillator, $29,220; hearttransplant, $38,970; knee replacement, $49,700; and peritoneal dialysis, $38,000

Ethics 773

Ethics

The ethics of cochlear implantation in adults was an issue in the 1970s, when thebenefits or risks were not clear Since then it became an important issue for infantsand children and has received a lot of attention, in particular from the signingdeaf community and their advocates The issues raised by the signing deaf com-munity concern, first, human experimentation, and second, whether it is natural

to have a hearing loss and to restore hearing This chapter examines cochlearimplantation in adults and children in the light of generally accepted ethical prin-ciples

Ethics is a general term referring to both morality and ethical theory In

con-sidering whether cochlear implantation in adults and in particular infants andchildren is morally acceptable, it is first necessary to also consider morality Mo-rality in general refers to social conventions about right and wrong human conductthat are widely shared by members of the community Common morality refers

to socially approved norms of human conduct In particular, it highlights able and nonacceptable conduct referred to in discussing human rights It is alsoimportant to consider moral theology, which provides a perspective on moralissues from a theological or religious point of view

accept-Human Experimentation

In considering the ethics or morality of cochlear implants, it is essential to mine to what extent the benefits outweigh the risks, and to what extent it is anaccepted clinical procedure and not primarily research The fundamentals can besummarized as: (1) do no harm; (2) do good; (3) achieve justice; and (4) ensureautonomy In considering these issues it is helpful, to view the procedure againstits background and history

deter-Research in the human with cochlear implantation which occurred in the 1970sand 1980s was carried out on the basis of ethically acceptable practices for re-search as laid down in the Helsinki Declaration on Biomedical Research involvinghuman subjects adopted by the 18th World Medical Assembly, Finland, 1969,and revised by the 29th World Medical Assembly, Tokyo, 1975, and in accordancewith the Convention on the Rights of the Child, adopted by the General Assembly

of the United Nations on November 20, 1989 These principles are summarizedbelow, with an explanation of how cochlear implantation has complied with theethics of human experimentation They have also been presented by Clark, Cowan

et al (1997)

Scientific Rigor

Biomedical research involving human subjects must conform to generally accepted entific principles, and should be based on adequately performed laboratory and animalexperimentation, and on a thorough knowledge of the scientific literature

sci-The biomedical cochlear implant research in the 1970s on adults was preceded

by extensive physiological and biological research on the experimental animal

774 13 Socioeconomics and Ethics

(Clark 1969; Clark, Nathar et al 1972; Merzenich et al 1973; Black and Clark1980) and the human temporal bone (Clark, Kranz et al 1975; Clark 1977) Themultiple-electrode studies on children were preceded by thorough speech andpsychophysics studies on adults, and the biological safety research on experi-mental animals The studies on children 2 years of age and under was carried outonly after the Nucleus multiple-channel implant had been show to be as effective

on children from 2 to 18 years, and approved by the FDA on June 27, 1990 Itwas only performed when the trend in results had shown that speech perceptionwas better the younger the child at implantation Finally, it was essential beforeoperating on children in this age group to ensure that the high incidence of middleear infection would not lead to a significant risk of inner ear infection, that headgrowth would not affect the implant and vice versa, and that electrical stimulationwould not have an adverse affect on the immature nervous system These concernswere addressed through the 5-year NIH contract for studies on pediatric auditoryprosthesis implants (contract No 1-NS-7-2342) awarded in 1987 to the University

of Melbourne

The design and performance of each experimental procedure involving human subjectsshould be clearly formulated in an experimental protocol that should be transmitted to aspecially appointed independent committee for consideration, comment, and guidance.The findings from cochlear implant research studies on adults and then childrenwere published in general in international journals with a high standard of peerreview and presented reliable information based on clearly formulated and achiev-able experimental protocols The same careful review was made by agenciesfunding the cochlear implant research, for example, the NIH, the National Healthand Medical Research Council of Australia, and the Australian Research Council.The FDA carefully reviewed the experimental protocols for any studies reported

to it This applied first to the 3M-House single-channel implant for which a PMAwas obtained in 1984 for awareness of sound in postlinguistically deaf adults,and the Nucleus multiple-channel device, which the FDA approved in 1985 assafe and effective in providing help in understanding speech with lipreading andalso some speech using electrical stimulation alone for adults who had hearingbefore going deaf The FDA approved the use of the Nucleus F0/F1/F2 andMultipeak strategies in children from 2 to 18 years of age on June 27, 1990.Biomedical research involving human subjects should be conducted only by scientificallyqualified persons and under the supervision of a clinically competent medical person Theresponsibility for the human subject must always rest with a medically qualified personand never rest on the subject of the research, even though the subject has given his or herconsent

The research in Melbourne has always been undertaken under the control ofthe Cochlear Implant Clinic of the Royal Victorian Eye and Ear Hospital Thehead of the clinic was an appropriately qualified medical person who was re-sponsible to the board of the hospital and the university As I was the head of theclinic and involved in the experimentation, a committee of the hospital assumed

Ethics 775

overall responsibility This committee had independent medical representationand an independent chairperson

Benefits Versus Risks

Biomedical research involving human subjects cannot legitimately be carried out unlessthe importance of the objective is in proportion to the inherent risk to the subject.The successful outcomes of implantation in adults and children with severe-to-profound hearing loss are now well documented in properly controlled studiesreported in international journals with a high standard of peer review, as are thecomplications of the procedure A major study funded by the NIH was undertaken

at the Central Institute for the Deaf (CID) where a group of profoundly deafchildren were managed with hearing aids, tactile aids, or cochlear implants Thespeech perception and production results from this study were reported by Geersand Brenner (1994) and Tobey et al (1994)

The study was longitudinal; 39 children with prelingual profound deafnesswere evaluated over a 3-year period while enrolled in the auditory-oral educationprogram at the CID in St Louis, Missouri The 39 children were matched intriads, 13 using cochlear implants (CI), 13 tactile aids (TA), and 13 conventionalhearing aids (HA) The cochlear implants were the Nucleus 22 multiple-channeldevices with the F0/F1/F2 and Multipeak strategies The primary focus of thestudy was to document differences, if any, in the rate of acquisition in speechperception, speech production, and spoken language with use of these sensorydevices The study used a stringent measure of benefit, requiring not only im-provement in children compared to themselves, but also compared to similarorally educated children using hearing aids

Initial scores on a battery of speech perception tests were similar for all threegroups After 36 months, there was a significant difference between the perfor-mance of the children using cochlear implants and the other two groups Withspeech perception, the cochlear implant group moved from a median category 1(detection only) to category 5 (consonant perception) In contrast, the tactile groupmoved from category 1 to category 2 (pattern perception), whereas the hearingaid group remained at category 2 over the entire 36 months of the study Inaddition, statistical analysis showed that feature perception for the three groupswas significantly different after 36 months of habilitation Although there were

no significant differences between the TA and HA groups, the CI group scoredsignificantly higher than the TA and HA group on pitch perception (95% versus65% and 84%), vowel perception (84% versus 35% and 42%), and consonantplace perception (36% versus 16% and 21%) The CI group also moved on thematrix phrase perception task from being the lowest of the three groups to thehighest Finally, after only 12 months, the speech-reading enhancement scores ofthe CI group were found to exceed those of children using either hearing aids ortactile aids

The CI group also demonstrated significantly higher scores than the TA and

HA groups in the production of vowels and consonants in spontaneous speech

776 13 Socioeconomics and Ethics

Children who used the cochlear implant for 3 years performed at a comparablelevel to children using hearing aids with a pure tone audiogram of 90 to 100 dB

HL The children in the CI group were also significantly more accurate in theirproduction of the less visible place and complex manner features and on somevoicing features, as compared to the TA and HA groups

In terms of spoken language, the CI group exhibited faster acquisition of alllanguage and communication skills measured The mean scores for the CI groupwere significantly higher than the TA and HA groups in the areas of expressivevocabulary, receptive syntax, and everyday use of sensory aid (Geers and Moog1994) Furthermore, an NIH Consensus Statement, volume 13(2), Cochlear Im-plants in Adults and Children, was issued in 1995, which concluded that, usingtests commonly applied to children and adults with hearing impairments, percep-tual performance increases on average with each succeeding year postimplanta-tion Over time, performance may improve to match that of children who haveresidual hearing and are highly successful hearing aid users Children implanted

at younger ages are on average more accurate in their production of consonants,vowels, intonation, and rhythm than older children Speech produced by childrenwith implants is more accurate than speech produced by children with comparablehearing losses using vibrotactile devices or hearing aids One year after implan-tation, speech intelligibility is twice that typically reported for children with pro-found hearing impairments, and continues to improve Oral-aural communicationtraining appears to result in substantially greater speech intelligibility than man-ually based total communication The nature and pace of language acquisitionmay be influenced by the age of onset, age at implantation, nature and intensity

of habilitation, and mode of communication Oral language development in deafchildren, including those with cochlear implants, can be training-intensive, andresults typically do not reach the levels of children of the same age with goodhearing

The risks of implantation have been reported by a number of surgeons andwere referred to in Chapter 10 A total of 6084 children worldwide had receivedthe Nucleus multiple-channel cochlear implant by September 1996 The incidence

of facial weakness (paresis) or paralysis for cumulative data reported to CochlearCorporation on the Nucleus 22 to 1998 was 0.43% in adults (22/5170) and 0.39%

in children (16/4051) (Roland 2000) In most of these patients the facial weaknessresolved A damaged device needing removal occurred in 0.17% of adults (9/5170) and 0.07% of children (3/4051); damage to the electrode with removal in0.23% of adults (12/5170) and 1.63% of children (66/4051); and incorrect elec-trode placement with device removal in 0.27% of adults (14/5170) and 0.32% ofchildren (13/4051)

The cumulative incidence for wound infection is 1.08% for adults (56/5170)and 0.72 for children (29/4051) (Roland 2000) This incidence is too high, and

is greater than that for hip replacement In a high proportion of those with woundinfection—32% for adults (18/56) and 17% in children (5/29)—it leads to deviceremoval There have also been a small number of children who have developedlabyrinthitis and meningitis, in particular those with the Mondini syndrome (Pat-

to others Concern for the interests of the subject must always prevail over the interests

of science and society

The rehabilitation of the first two adult patients operated on by the University

of Melbourne team in 1978 and 1979 was a requirement of the program and hascontinued to be the case (Re)habilitation has always been the first priority evenwhen there was a need to do speech and psychophysical research studies Withthe study on children for the FDA, training and assessment preceded any researchinvestigation Concern for the interests of the subject has also been shown byindustry Industry should act in such a way that there is continuity in patientmanagement if there are sales or takeovers In this latter situation, Cochlear Lim-ited has provided continuity for implant patients when it acquired control of the3M-House and Vienna, Richards Ineraid as well as the Laura patients

Physicians should abstain from engaging in research projects involving human subjectsunless they are satisfied that the hazards involved are believed to be predictable Physiciansshould cease any investigation if the hazards are found to outweigh the potential benefits.The studies on adults at the University of Melbourne’s clinic at the RoyalVictorian Eye and Ear Hospital were preceded by investigations on the experi-mental animal The physiological, behavioral, and biological safety data weresubsequently shown to predict effects in human subjects The hazards in carryingout cochlear implantation on children could in general be predicted on the basis

of experience with adults In the case of infants and young children, there werespecial biological safety issues: the effects of implantation on head growth, theeffects of head growth on the lead wire assembly, the effects of implantation andelectrical stimulation on tissue in the young animal, the effects of explantationand reimplantation if a replacement electrode was required some years later, andthe likelihood of labyrinthitis postimplantation because infants are prone to epi-sodes of otitis media These special issues have been studied under an NIH con-tract No 1-N5-7-2342 and the results are outlined in Chapter 3

Furthermore, at each stage of the program, a multidisciplinary team assessedthe benefits for each adult, and children’s results were discussed with the parents

Privacy

The right of the research subject to safeguard his or her integrity must always be respected.Every precaution should be taken to respect the privacy of the subject and to minimize

778 13 Socioeconomics and Ethics

the impact of the study on the subject’s physical and mental integrity and on the personality

of the subject

It is the University of Melbourne’s clinical practice to minimize the impact ofpublicity on the adult by providing individual discussion with the case manager.Children’s physical and mental integrity and personality are respected by provid-ing guidance to parents in their management at home and at school Regularmeetings are held with the parents and the child’s teacher to ensure that all aspects

of the child’s welfare are considered This includes guidance on how to deal withinterest from children in a mainstream school, and on how to cope with anytensions created by signing deaf peers Later, as teenagers, they need assistance

in coping with any self-consciousness about being different in using the device.These issues were discussed in Chapter 11 At the University of Melbourne allrecords are treated as confidential and no public exposure is obtained withoutdiscussion and written permission

In publication of the results of his or her research, the physician is obliged to preserve theaccuracy of the results Reports of experimentation not in accordance with the principleslaid down in this declaration should not be accepted for publication

The published results from the University of Melbourne/Bionic Ear Instituteand other centers in the cochlear implant field have been validated by other mul-ticenter studies It is the aim at the University of Melbourne to report the findings

in scientific journals and meetings regardless of how well they fitted expectations,and it is required that Cochlear Limited and other firms report any faults orproblems to the FDA

Informed Consent

In any research on human beings, potential subjects must be adequately informed of theaims, methods, anticipated benefits, and potential hazards of the study and the discomfort

it may entail They should be informed that they are at liberty to abstain from participation

in the study and that they are free to withdraw their consent to participation at any time.The physician should then obtain the subjects’ freely given informed consent, preferably

To ensure that the information has been understood, it is the procedure torequire another person, for example, an independent doctor, to ask simple ques-tions of the parent and child, such as, “What do you expect to get out of theprocedure, and what are the risks?”

It is accepted that parents act on behalf of their children when the children are

Ethics 779

not of an age to understand the risk/benefits or to make an informed decision.This is not the case with older children, in which case both the children and theparents are involved in making the decision

When obtaining informed consent for the research project, the physician should be ticularly cautious if the subject is in a dependent relationship to him or her or may consentunder duress In that case the informed consent should be obtained by a physician who isnot engaged in the investigation and who is completely independent of this official rela-tionship

par-It has been the practice by University of Melbourne/Royal Victorian Eye andEar Hospital to require the consent form to be discussed with the patient by both

a surgeon on the team as well as independently by a noninvolved medical titioner or lawyer This now applies only for new research projects that mayinvolve greater risk

prac-In case of legal incompetence, informed consent should be obtained from the legal guardian

in accordance with national legislation Where physical or mental incapacity makes itimpossible to obtain informed consent, or when the subject is a minor, permission fromthe responsible relative replaces that of the subject in accordance with national legislation

It is the University of Melbourne/Royal Victorian Eye and Ear Hospital’s tice to arrange for older children with mental or severe physical handicaps toconsult psychological, psychiatric, or pediatric specialists to help determine thechild’s ability to give informed consent With young children, it is the parents’responsibility to give consent, as it is a therapeutic procedure

prac-The research protocol should always contain a statement of the ethical considerationsinvolved and should indicate that the principles enunciated in the present declaration arecomplied with

The patients’ consent forms in use in the Melbourne Cochlear Implant Clinicinclude a Statement of Patient Rights, based on the requirements of the NationalHealth and Medical Research Council of Australia This statement is consistentwith the Helsinki declaration In all cases, the individual rights of patients to thehighest quality of health care is paramount in the considerations of the RoyalVictorian Eye and Ear Hospital ethics committee

Rights of Children

The rights of the child having a cochlear implant should also be considered inrelation to the Convention on the Rights of the Child adopted by the GeneralAssembly of the United Nations on November 20, 1989 These rights are dis-cussed by Clark, Cowan et al (1997) Specific articles of direct relevance to theethics of cochlear implantation in the child are discussed and quoted as follows:Article 3.1: In all actions concerning children, whether undertaken by public or privatesocial welfare institutions, courts of law, administrative authorities or legislative bodies,the best interests of the child shall be a primary consideration

780 13 Socioeconomics and Ethics

The best interests of children are served by a careful evaluation by the disciplinary cochlear implant team to determine if they will benefit by commu-nicating in a world of sound Discussions with the parents and consultation withthe teachers of the deaf are an important component in ensuring that the bestinterests of the child are paramount

inter-Article 5: State parties shall respect the responsibilities, rights, and duties of parents or,where applicable, the members of the extended family or community as provided for bylocal custom, legal guardians, or other persons legally responsible for the child, to provide,

in a manner consistent with the evolving capacities of the child, appropriate direction andguidance in the exercise by the child of the rights recognized in the present convention.The rights of parents or a sole unsupported parent to decide what is best forthe child is accepted if it is a therapeutic procedure such as a cochlear implant.The cochlear implant is a therapy for a sensory disability Furthermore, in accordwith the worldview embodied in the United Nations Universal Declaration ofRights, the child is involved in the decision-making process from the earliestpossible stage

This is understood to mean that if a child has lost sufficient hearing to benefitfrom a hearing aid and has the potential to communicate with the help of acochlear implant, it is a responsibility of the clinic to explain this to the parent(s)

or guardian At least 50% of the factors affecting postoperative performance arenow established and can help in guiding in the best course of action for the child.Article 12.1: States parties shall assure that the child who is capable of forming his or herown views has the right to express those views freely in all matters affecting the child,the views of the child being given due weight in accordance with the age and maturity ofthe child

The older the children, the more responsibility they need to be given in decidingwhether to have a cochlear implant This is especially important as the results ofcochlear implantation are not as good and are more variable in older childrenwho have had a longer duration of deafness A full and free discussion should beundertaken It is, however, a complex matter in assessing the competence of thechild to make decisions

Article 18.1: State parties shall use their best efforts to ensure recognition of the principlethat both parents have common responsibilities for the upbringing and development of thechild Parents or, as the case may be, legal guardians have the primary responsibility forthe upbringing and development of the child The best interests of the child will be theirbasic concern

It is important to recognize that parents have the right to decide the care neededfor their child on the basis not only of the future needs of the child to fit intosociety, but also of the communication needed at home Parents with hearingprefer their children to be able to communicate with them in an auditory/oralmode as well as with their friends They also want them to have the greateropportunities later in life from being able to communicate in a world of sound.Approximately 85% to 90% of deaf children are in families with normal-hearing

Ethics 781

parents In contrast, if two deaf parents have a deaf child, that child can stilldevelop hearing with a cochlear implant and also be able to sign and communicatewith the parents The two educational modes are not mutually exclusive, providedthe cochlear implant is carried out at an early age during the child’s critical periodfor speech and language development

Article 23.1: States parties recognize that a mentally or physically disabled child shouldenjoy a full and decent life, in conditions that ensure dignity, promote self-reliance, andfacilitate the child’s active participation in the community

Article 23.2: States parties recognize the right of the disabled child to special care andshall encourage and ensure the extension, subject to available resources, to the eligiblechild and those responsible for his or her care, of assistance for which application is madeand which is appropriate to the child’s condition and to the circumstances of the parents

or others caring for the child

If a physically or mentally disabled child receives a cochlear implant, then theUniversity of Melbourne’s clinic at the Royal Victorian Eye and Ear Hospitaltakes special care to ensure that there are adequate educational, rehabilitation,and other resources to support the child In children with multiple handicaps andespecially with minimal mental retardation and learning disorders, the speechperception will not be as good as with matched controls and learning will takelonger (Pyman et al 2000) Nevertheless, in a few years they can achieve goodspeech results and even though not quite the same as with a child without thesedisabilities, the benefit can be of great value

Article 23.3: Recognizing the special needs of a disabled child, assistance extended inaccordance with paragraph 2 of the present article shall be provided free of charge, when-ever possible, taking into account the financial resources of the parents or others caringfor the child, and shall be designed to ensure that the disabled child has effective access

to and receives education, training, health care services, rehabilitation services, preparationfor employment, and recreation opportunities in a manner conducive to the child’s achiev-ing the fullest possible social integration and individual development, including his or hercultural and spiritual development

Article 24.1: States parties recognize the right of the child to the enjoyment of the highestattainable standard of health and to facilities for the treatment of illness and rehabilitation

of health States parties shall strive to ensure that no child is deprived of his or her right

of access to such health care services

The highest standard of help for the child and parents is best achieved throughthe support of a team or clinic rather than a single clinician The clinic should behospital-based with strong links to the educational authority The clinical teamshould also be able to provide considerable support to the home or school Thesupport services provided by the firm manufacturing the device is also an im-portant consideration

Article 28.1: States parties recognize the right of the child to education, and with a view

to achieving this right progressively and on the basis of equal opportunity, they shall, inparticular (a) make primary education compulsory and available free to all; (b) encourage

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the development of different forms of secondary education, including general and tional education, make them available and accessible to every child, and take appropriatemeasures such as the introduction of free education and offering financial assistance incase of need; (c) make higher education accessible to all on the basis of capacity by everyappropriate means; (d) make educational and vocational information and guidance avail-able and accessible to all children; (e) take measures to encourage regular attendance atschools and the reduction of dropout rates

voca-It has been shown in a number of studies (e.g., Walker and Rickards 1993) thatthe language development of severely to profoundly deaf children lags behindthat of their normal-hearing peers Fewer deaf children succeed at secondary ortertiary education, especially when using sign language of the deaf Cochlearimplants offer the possibility for more children to utilize their educational poten-tial

Article 29.1: States parties agree that the education of the child shall be directed to (a) thedevelopment of the child’s personality, talents, and mental and physical abilities to theirfullest potential; (b) the development of respect for human rights and fundamental free-doms, and for the principles enshrined in the Charter of the United Nations; (c) the de-velopment of respect for the child’s parents, his or her own cultural identity, language andvalues, for the national values of the country in which the child is living, the country fromwhich he or she may originate, and for civilizations different from his or her own; (d) thepreparation of the child for responsible life in a free society, in the spirit of understanding,peace, tolerance, equality of sexes, and friendship among all peoples, ethnic, national, andreligious groups, and persons of indigenous origin; (e) the development of respect for thenatural environment

The cochlear implant must ultimately help the child to be a well-rounded,mature individual capable of living with self-reliance in society Developing com-petence in language helps achieve this goal There is also no reason why a childwith an implant and auditory/oral communication should not be able to com-municate with and have friends in the deaf signing community

Attitudes of Hearing-Impaired People

People Who Have a Postlinguistic Hearing Loss

The majority of deaf people have a postlinguistic hearing loss Most of them havelost hearing in adulthood Thus their social contacts are with those who havehearing The severe-to-profound loss makes social intercourse and work difficult,and they miss everyday meaningful environmental sounds They have from theoutset welcomed the restoration of hearing with a cochlear implant even if theyexperience only a minimal return

People Who Use Sign Language

Sign language can either be signed English or sign language of the deaf Theformer complements the auditory input from a cochlear implant or hearing aid.The latter is a distinctive language with its own grammar, as discussed in Chapter

in all areas of medicine In most societies parents have the responsibility of termining the education and health needs of their children, and a majority prefertheir children to have the opportunity to communicate in a hearing world with acochlear implant (2) Deafness is a natural state There is, however, no basis forthis claim through recourse to either religious or scientific views Even from apostmodernist point of view, there is little to support the contention (3) Deafpeople are viewed as of lesser value by people with normal hearing This view

de-is fostered by referring to people as “the signing deaf.” It de-is thus important not

to use this term as it is depersonalizing and makes it more difficult to be a part

of a community that accepts diversity (4) There are health and other risks to theprocedure Many of these concerns have been due to lack of information It isdifficult for the average profoundly deaf person using sign language to obtain theright information about the procedure Their communication difficulty itselfmakes this difficult This emphasizes the great need for more open dialogue withsmall groups where concerns can be expressed in an open and accepting envi-ronment

Blamey, P J., J Sarant, L Paatsch, et al 2001 Relationships among speech perception,production, language, hearing loss, and age in children with impaired hearing Journal

of Speech, Language and Hearing Research 44: 264–285

Clark, G M 1969 Hearing due to electrical stimulation of the auditory system MedicalJournal of Australia 1: 1346–1348

Clark, G M 1977 An evaluation of per-scalar cochlear electrode implantation techniques

An histopathogical study in cats Journal of Laryngology and Otology 91: 185–199.Clark, G M., R S C Cowan and R C Dowell 1997 Ethical issues In: Clark, G M.,

R S C Cowan and R C Dowell, eds Cochlear implantation for infants and children.Advances San Diego, Singular Publishing Group: 241–249

Clark, G M., H G Kranz, H J Minas and J M Nathar 1975 Histopathological findings

in cochlear implants in cats Journal of Laryngology and Otology 89: 495–504

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Clark, G M., J M Nathar, H G Kranz and J S Maritz 1972 A behavioral study onelectrical stimulation of the cochlea and central auditory pathways of the cat Experi-mental Neurology 36: 350–361

Cowan, R S C 1997 Socioeconomic and educational management issues In: Clark,

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Cowan, R S C., C D Brown, L A Whitford, et al 1995 Speech perception in childrenusing the advanced SPEAK speech-processing strategy Annals of Otology, Rhinologyand Laryngology 104(suppl 166): 318–321

Dawson, P W., P J Blamey, S J Dettman, et al 1995 A clinical report on speechproduction of cochlear implant users Ear and Hearing 16: 551–561

Dawson, P W., P J Blamey, L C Rowland, et al 1992 Cochlear implants in children,adolescents and prelinguistically deafened adult: speech perception Journal of Speechand Hearing Research 35: 401–417

Dowell, R C., P J Blamey and G M Clark 1995 Potential and limitations of cochlearimplants in children Annals of Otology, Rhinology and Laryngology 104(suppl 166):324–327

Downs, M P 1986 Psychological issues surrounding children receiving cochlear implants.In: Mecklenburg, D J., ed Cochlear implants in children: seminars in hearing NewYork, Thieme Medical: 383–406

Evans, A R., T Seegar and M Lehnhardt 1995 Cost-utility analysis of cochlear implants.Annals of Otology, Rhinology and Laryngology 104(suppl 166): 239–240

Evans, B M., P Dallos and R Hallworth 1989 Asymmetries in motile responses of outerhair cells in simulated in vivo conditions In: Wilson, J P., ed Cochlear mechanisms.New York, Plenum: 205–206

Flynn, M C., R C Dowell and G M Clark 1996a Speech perception for hearing aidusers versus cochlear implantees Journal of the Acoustical Society of America 100:2692

Flynn, M C., R C Dowell and G M Clark 1996b Speech perception in people with asevere hearing loss: preliminary resullts Australian Journal of Audiology 17(suppl):40–41

Flynn, M C., R C Dowell and G M Clark 1997 Speech perception of hearing aid usersversus cochlear implantees In: Clark, G M., ed Cochlear implants XVI World Con-gress of Otorhinolaryngology Head and Neck Surgery Bologna, Monduzzi: 261–265.Flynn, M C., R C Dowell and G M Clark 1998a Aided speech recognition abilities

of adults with a severe hearing loss Journal of Speech and Hearing Research 41: 285–299

Flynn, M C., R C Dowell and G M Clark 1998b Speech recognition in adults with asevere hearing impairment Australian Journal of Audiology 20(suppl): 62

Fraser, J G 1987 UCH/RNID cochlear implant programme-an overview: patient selectionand surgical technique In: Banfai, P., ed Cochlear implant: current situation Proceed-ings of the International Cochlear Implant Symposium Sept 7–12 Duren, West Ger-many 273–279

Geers, A E and C Brenner 1994 Speech perception results: audition and lip-readingenhancement Volta Review 96: 97–108

Geers, A E and J S Moog 1994 Effectiveness of cochlear implants and tactile aids fordeaf children Volta Review 96: 1–231

Geers, A E and E A Tobey 1995 Longitudinal comparison of the benefits of cochlear