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Cochlear Service Report - January 2024

Cochlear Implants and Children with Additional Special Needs

Cochlear Implants and Children with Additional Special Needs
Holly Whalen, AuD, CCC-A, Melissa H. Sweeney, MS, CCC-SLP, LSLS, Cert. AVT
October 29, 2012
This article is sponsored by Cochlear Americas.

This article is a transcript of a live webinar presented by Cochlear Americas on AudiologyOnline as part of their HOPE series. To view other HOPE courses, please visit: Cochlear Online Courses. Please download supplemental course materials.

Melissa Sweeney:  This is a topic that is definitely near and dear to our hearts, but we also recognize that it is a very broad topic.  We are hoping to touch on a lot of the issues at hand, but this is definitely an area that can be looked at in more detail than what we will address today. 

It is estimated that about 30% to 40% of children who are deaf and hard of hearing have additional diagnoses (Centers for Disease Control, 2012).  At the Callier Center in Dallas, we have a number of children with other health care needs such as autism, CHARGE, cytomegalovirus (CMV), meningitis, cerebral palsy, Goldenhaar syndrome, Waardenburg syndrome, various Trisomy disorders and other sensory integration issues.  These are children that we see quite frequently.  Looking at surveys and studies, some implant centers have as many as 25% to 50% of their population with multiple issues at hand (Johnson & Wiley, 2009).  This number is increasing over time due to the fact that testing and programming techniques require less and less participation on the part of the child.  Our program strongly believes the children with multiple disabilities can benefit from a cochlear implant, and we have many children that do receive benefit from the cochlear implant. 

For children who are deaf and have multiple disabilities to benefit and be successful, it requires several things:  a thorough evaluation, consistent monitoring of progress over time, and dedication by the child’s family in a total team approach.

Candidacy Evaluation

Holly Whalen: We look at a number of different things in the candidacy evaluation.  First, are they audiologically a candidate for a cochlear implant?  Do we think they are going to receive more benefit from a cochlear implant than with their current hearing aids?  Will the child be able to use this information and demonstrate some functional auditory skills?  Do they have the potential to develop spoken language?  Will an implant improve overall communication, and if so, what types of improvement do we expect from these children?  Is their overall quality of life going to improve?  Do we think the child's general communication is going to improve, and what strategies can we use to elicit the most improvement?  And are there any medical contraindications that we need to look at prior to surgery?  That is something that the cochlear implant surgeons are going to talk about with any other medical professionals that these children may also see.

An MRI is obtained on all children as part of the candidacy evaluation.  We look at the MRI to determine if there are any structural concerns or nerve deficiencies that would preclude a child from being an ideal cochlear implant candidate.  This is especially important in children who have other diagnoses that will affect overall development as well.  The patient and family will have an appointment with the surgeon to discuss the findings of the MRI.

We will also look at genetic testing when it is available.  We may have discussions with reimbursement and business offices to look at how much a family can be expected to pay over a lifetime with this decision to get a cochlear implant.  We look at speech-language evaluations and ongoing audiological evaluations.  We are going to gather information from the school district, early childhood intervention (ECI) therapists, teachers and any other professionals that may have worked with or evaluated the child.  Oftentimes, they can add more to the overall picture of that child that we may not see in our initial evaluation.

Once we have gathered all of this information, we are going to do a family meeting with different team members.  We are going to discuss all the test results and the prognosis for how we believe they will do with the cochlear implant.  We also look at the devices and let the families get a hands-on feel for the implant and the processors.  However, the most important thing we are going to talk about in that meeting is expectations and how to have appropriate expectations for a child candidate.

We are also going to talk about the timeline of this implantation and candidacy process.  Oftentimes, things with children are going to move a little bit slower than families sometimes anticipate.  Looking at all these criteria is very important when we are making this kind of surgical decision.  A typical evaluation that an audiological needs is very standard: unaided testing in each ear, aided testing with appropriate amplification in each ear and speech perception testing using tests such as the ESP (Early Speech Perception test), the GASP (Glendonald Auditory Screening Procedure), LNT (Lexical Neighborhood Test), MLNT (Multisyllabic Lexical Neighborhood Test), PBK (Phonetically Balanced Kindergarten Test), or the HINT (Hearing in Noise Test).  We do these in quiet and in noise.

Children with special needs are often unable to complete this standard test battery with traditional testing techniques.  This may be due to things like limited motor skills, global developmental delay or other cognitive delays that keep them from being able to participate in more traditional testing.

Auditory brainstem response (ABR) testing for some of these children is going to be the primary test used to diagnose hearing loss, but behavioral testing is also very important.  It can show us the child’s functional skills and their ability to be conditioned to a task.  Conditioning with these children can sometimes be very difficult.  It is imperative that we are able to distinguish a good response from true lack of response because they cannot hear and lack of response because they are physically unable to do the task.

Sometimes we will try to condition by pairing an auditory stimulus with a vibrotactile stimulus, like the bone oscillator.  We will try to do something like visual reinforcement audiometry (VRA), where the child will hear it or feel it and look at the reinforcing toy or light.  Conditioning them to the task first with the added vibrotactile information can be helpful as we take that away.  We can then discern if they are really hearing the auditory signal after we know they are really conditioned to the toy or the task at hand.  It is also helpful to know if you cannot condition a child to a vibrotactile response. 

We use children's music to help elicit a response that we are not getting through speech or tonal stimuli.  I have a patient with a cochlear implant that was getting difficult to test after a while and we were not getting good responses.  Mom mentioned that “sometimes he will respond to music at home.”  Using this suggestion, I put him in the booth, put on children's music through the audiometer, and he would rock back and forth to that music, even at a very soft levels, giving us lots of good information that he was responding and hearing things.  Mom was thrilled at these responses.  So this is also another way to get good information.

Next, include the child's speech pathologist or therapist.  Find out what a typical response may be and what those people are seeing in the therapy session.  They see the child weekly, and they get good at picking up what a typical response for that child may be.  They can help you to transfer that into your testing scenario.

You may, with those children, use something that they do the same in every single appointment with the therapist.  They use the same toy or they play the same game with the same person, and then you can transfer that over with what you are doing in the booth.  Sometimes you may need more than one technique.  Incorporating VRA, conditioned play audiometry (CPA) and behavioral observation audiometry (BOA) in the same appointment can sometimes be very helpful.  It depends very much on that child and how you can best elicit responses from them.

Speech Perception Testing

Many children with additional needs are not going to be able to complete traditional types of speech tests.  Parent report measures can be very helpful.  This will help us to gain information that we cannot get from formal testing.  I also find it is a great way to get more information from parents by asking them to give you examples of what they are seeing their child do at home.  It also helps to make sure you are on the same page with that parent in terms of the information you are trying to gather.  I asked one parent if their child was imitating anything at home.    And the dad said, “All the time.”  I said, “Can you give me an example of that?”  Dad said, “When I put my hands on my hips, she does the same thing.”  I realized we were not talking about the same thing!

Training tasks, such as the ESP low-verbal, can be helpful.  You can do training tasks with pattern perception, rather than word recognition, to look at a couple of things.  Is that child able to differentiate something like “ahhhhhh” versus “hop, hop, hop,” and are you able to condition them to be able to pick out any sort of pattern differences?  This gives you a lot of information about what auditory skills the child has and what you are able to train them to do.

Speech-Language Evaluation

Melissa Sweeney: We look at several things on the speech-language evaluation during the candidacy phase.  We will get a good idea of their receptive and expressive language skills.  Sometimes, of course, children with hearing loss that have additional special needs may or may not even have a formal communication system established.  We want to look at how they are communicating overall.  Are they using any gestures? Do they understand any words mom says? Are they trying to say anything?

We may do this by completely using informal observation techniques at this stage, but we also try to administer some formal measures. We may have to do something that is more along the lines of the child's developmental level rather than their chronological level.  Ideally, we try to administer a measure in both areas.

In our program, we use the REEL, which is the Receptive Expressive Emergent Scale III.  We use the Reynell Developmental Language Scales and the MacArthur Bates Communicative Development Inventories (CDI).  We use both the oral and written language scales for our language measures.  We also perform an articulation evaluation, which may be informal, especially during this phase.  We may only be taking an inventory of the different sounds we hear the child producing spontaneously and possibly during imitation.

We also want to evaluate the child's oral-motor skills.  As thorough of an evaluation as we can complete is important because sometimes children with some of the diagnoses that we mentioned earlier will also have oral-motor difficulties, and we want to look at that so we can later talk about how that may impact future speech development.

We also want to evaluate the child's communication attitudes.  Are they trying to communicate with us, and how are they trying to do that?  Are they trying to use their voice, or say any words?  Getting a good overall idea of the child's communication skills is very important, no matter the communication system the child may have been introduced to at this point.

We also want to look to see if they are using listening for communication at all.  Do they alert to sounds in their environment?  Do they respond to their name?  For many of these children, the nonverbal communication is what we are able to get the best information on, so we look at things like eye contact, joint-attention and turn-taking skills.

After all of these evaluations are completed, we sit down and talk about all of the test results during our parent or family meeting, as well as the factors that we know are related to implant success.  Certainly, chronological age is very important.  Duration, or the time the child has had a hearing loss is a contributing factor, as is their medical or radiological information.  We factor in any known diagnoses or multiple disabilities the child may have, their hearing aid use, expressive language skills, oral-motor skills and speech communication attitude.  We also spend some time talking about any behavioral concerns we may have, such as if the child has any sensory difficulties or impulsive behaviors that we feel like would impact the audiologist when programming the device after implantation or that would interfere with the child participating in therapy on a weekly basis.  We want to talk with the families about that ahead of time to prepare them for some of the things that we see as difficulties that we may have to work with.

We also look at the family structure and support.  We look at the family's expectations.  We talk with the family about the educational environment that child is in at the time and what recommendations we might have that would require change.  We are also looking at the availability of support services.  In Texas, of course, we are a large state with a lot of rural areas, and sometimes families coming to us live in areas where there just are not a lot of support services available, so we talk about what services the child will need following implantation and try to help them establish some type of plan for getting those services.

We discuss how all these choices and their support affects the child's prognosis with a cochlear implant.  We will express our concerns, if there are any, and then try to help the family develop some appropriate expectations. We definitely want to explain to the family that the primary purpose of the cochlear implant is to provide the child with more access to sounds, and because that is the cochlear implant's job, that does not mean that it will have an impact if a child has a significant cognitive delay.

It is very important for the family and all the other individuals working with the child to have appropriate expectations and realistic goals.  Sometimes hearing may not be the most significant concern for a child or a family at a given time, and we may need to address some other areas more immediately first.  If there is any suspicion of another diagnosis at that time that has not been addressed, it is also important then to look at the child as a whole and make those necessary referrals.  We want expectations that are consistent among all the team members so the family will hear the same information, no matter which team member they are talking with. 

We try also to break down some of these goals into smaller, more attainable successes, so that after the child receives the implant, the family sees what type of path we are going to take, and they are able to get excited about that, especially when we see the child achieving those goals along the way.

When we are working closely with the family, it is important that we refer the child to an additional professional if we recognize any type of atypical behavior or developmental or health concerns.  Some referrals may include neurologists, developmental pediatricians, developmental psychologists, psychiatrists, geneticists, occupational therapists, infectious disease specialists, or maybe other speech-language pathologists who have areas of expertise, such as augmentative and alternative communication (AAC).  We know firsthand that sometimes it is hard to make those referrals and make them seamlessly, especially if you are looking at different pay sources for the child.  It can be difficult to find another provider who may accept whatever insurance coverage that child has, but we know it is very important to have on hand a variety of good professionals to which you can refer.

Initial Stimulation

Holly Whalen: Once we have looked at this evaluation and decided that a cochlear implant is the way we want to go for that particular child, we start looking at their initial stimulation.  The following is true of any child: you are never going to be able to predict how they are going to respond at that initial hookup.  This is especially true for children with additional health care needs, and it is important that the family and other health professionals working with the family understand this. 

Sometimes a child may be limited to “no response” at that initial activation.  Children with other needs and other possible anatomical concerns may require more time to get the map where you would like it to be.  Programming for all children with cochlear implants is a journey, and some children may take more time than others.   We want to make sure that the family understands this from day one.  By preparing them from the beginning, it helps reduce any sort of disappointment that may occur at the initial stimulation.  Some parents have an idea in their head of how the initial stimulation will go and they are disappointed when that does not happen.  Some children with severe sensory issues may not be able to tolerate the device in the beginning, even without any stimulation.  Sometimes we will just put the device on the child without turning it on so they can get used to the feeling of having something on their head. 

When we have parents who say, “My child will not wear hearing aids,” we talk to them in depth about consistently wearing hearing aids, not just to see if they get any benefit from them acoustically, but because committing to an implant is committing to wearing a processor on the head at all times.  That can be very important, especially with children with sensory difficulties.  Once the child is able to tolerate the device on their head turned off, then we can gradually start to add the stimulation, and that helps to keep them from getting overwhelmed by the device. 

The most important aspect of having a cochlear implant is consistency.  It can be very difficult for caregivers to keep the device on the child’s head.  Retention can be a big issue for these kids, especially if they have anatomical issues.  Headbands and hats are sometimes recommended, but it is important to be careful that that coil of the processor is not slipping out of range of the internal implant.  The coil can shift over, away from the internal magnet, but still be held on their head by that hat or headband.  Now with indicator lights on a lot of processers, we can reduce that concern, but it is something to be aware of.

Double-sided tape is also another option, but you have to have families watch for any sort of irritation or redness on the skin.  I have had parents pull out clumps of their child's hair at appointments trying to get that toupee tape off, so while it can be a useful retention device, you do have to watch out for any adverse reactions.

Wheelchairs with headrests can also make keeping the coil on very difficult, especially in bilateral recipients.  Padded headrests that sit lower around the head and neck are sometimes easier to work with than those with a metal backing, but it depends greatly on the child's head control.  The metal backing will sometimes attract the magnetic coil and pull it off the child’s head.  If this is a potential concern for a patient, it can be helpful to discuss placement options with the surgeon prior to surgery.

It may take several weeks, even months, of different trials of wearing options to find the best fit for these children.  Children with malformed pinnae may pin the processor on their shirt and use a longer coil to connect to their cord.  Other children may need to wear the processor on the ear to get it to stay on.

Moreover, it is very important for caregivers to understand where the microphone is located on these devices.  I have had many families think they were doing well at keeping the processor on, only to notice that they actually covered the microphones with toupee tape in an effort to keep it on their ear.  Another thought is that if a child is wearing the processor pinned to their shirt in the winter, coats or scarves over their shirt can cover up the microphone or make a scratchy, muffled noise under the fabric.  These are things you might not ordinarily think about, but become important to an implant user.

A lot of families feel like if they could just get that magnet to stay on more securely, it would be better.  However, increasing the magnet strength in the coil may not solve the problem, but actually create one.  A magnet that is too strong is dangerous to the patient's skin flap.  Making sure parents understand the consequences of tightening the magnet themselves can be very important.  We have had several parents that have taken it upon themselves to change the magnet, even after numerous people have warned them against it, with some very difficult outcomes.

Rehabilitation and Therapy

Melissa Sweeney: We have two main goals when it comes to rehabilitation.  One is to improve the child's auditory and listening skills with the cochlear implant, and the second is to establish a functional communication system for the child.  Of course, these goals can be very difficult and they are certainly individualized for each patient.  I am going to touch on some of the different strategies and considerations that you would want to look at when making these decisions.

Tips to Improve Listening Skills

If you are used to working with children who have cochlear implants or children with hearing loss, these strategies for developing listening are probably very familiar to you.  We are going to use these same types of strategies, but we may have to change our approaches in certain areas to make them work best for each child.

The first strategy is to create a listening environment.  That is simply accomplished by making our room quieter, taking any of the noise out and making sure we are sitting at a good distance from the cochlear implant recipient; not completely on the opposite side of the room.

We also want to create a communicative environment.  That is accomplished by making sure we have set up an environment that provides the child real reasons to communicate back and forth with us.  We do not necessarily want to be handing different objects to the child over and over and over again.  We want to set up situations where they are required to communicate something to us.  That, of course, will depend on what level of communication skill the child has. 

The hand cue is another strategy that we use.  You may be familiar with that.  That is simply putting our hand slightly in front of our mouth so that the child is not able to watch our lips.  That takes away the visual information from the child.  It helps them, one, not get the visual information, but two, to let them know that this is something important to listen for.  It can also act as a cue for verbal types of turn taking.

Acoustic highlighting is another strategy.  That is simply making spoken language easier to hear.   It could be taking away any of the extra noise in the room.  It could be using speech that is rich in melody and pitch.  It could be contrasting specific speech sounds in a sentence. It could be emphasizing specific speech sounds in a sentence.  Whatever makes it easier for that piece of spoken language to be heard, that is what acoustic highlighting is.

The auditory sandwich is another strategy that can be used.  Auditory sandwich is simply providing auditory only information, following it with something visual and then following that with the auditory only again.  For instance, you could give the child a direction without any of the visual information, so auditory only, and then the child did not respond, you might provide some visual information.  Maybe the child can watch your mouth.  Maybe the child sees you sign something, or maybe it is some other type of communication system like a picture system or augmentative device.  No matter what the child's communication system is, you have given that visual piece of information and then follow it with auditory information only.

Parent participation in therapy is key for all children with cochlear implants, but is even more so for children who have additional diagnoses.  Providing parents opportunities to practice different strategies in your therapy section is critical to get them feeling comfortable with the things you are asking them to do.  They, of course, can provide you with some information about things they have observed in their child since the previous session, and that is really paramount for the parent.  Seeing and providing feedback allows them to feel more confident in what they are doing with the child and understand the things that you are looking for.

Using a dialogue or back-and-forth types of turn taking is very important, no matter what communication system that child is using.  So is following a developmental order, which means starting with at whatever developmental level the child is at and moving forward in a developmental sequence.  One of my favorite resources for that is the Listen, Learn and Talk resource that is available through Cochlear Americas.  It is broken down into small steps and is a very good resource to have on hand so you can see listening skill developmental order side-by-side with language skills.  I also use the CASLLS (Cottage Acquisition Scales for Listening, Language & Speech).  You might be using a developmental level that is less than what the child's chronological level is.  I do like that tool as well.  These are just two out of many.

Following the child's lead and being flexible is critical, especially with children who have needs besides hearing loss.  Sometimes you do have to throw out your best laid plans because you start to observe something in a child that you were not expecting, and you follow the child’s lead instead of your daily therapy plan.  Being flexible in your plan is really critical for their success.

Move Along a Continuum of Cueing

We want to be using the least amount of cueing possible, but still have the option to move to the most amount of cueing that we need to whenever that is necessary.  Of course, that is very individualized and independent for each child. 

Some of the important considerations that we need to think about when working with children is their developmental level, their motor limitations and sensory needs, if any.  In any of the activities we do, we have to make sure that one of these areas is not going to prevent the child from participating in that activity.  We also want to make sure that these considerations are not going to affect whatever communication mode we select for the child.  One example that I am thinking of is some of the kids that we have seen who have come in with significant motor limitations.  They have been placed in sign language classrooms or exposed to sign language, which is not necessarily the wrong thing to do with them, but we know that the significant motor limitations with the arms and hands will limit their ability to use sign language well.  So consider all of these things when you are making that decision for a child. 

When establishing a child’s communication mode, we certainly do not want to limit ourselves to one method.  We do not want to get caught up in only one type of sign language or only use oral systems.  We want to make sure we are using whatever method or mode is best for that child.

Children with cochlear implants and additional special needs may need alternative modes, but we want to make sure we have done a thorough assessment and given every consideration to an alternative method.  Picture systems and other augmentative communication devices can be perfectly appropriate if that is what is determined to be the most beneficial for the child.

Recognize that strategies may change over time for a child.  If you start with one plan, do not feel like you are stuck in it.  If you do change paths, however, be clear to parents and caregivers that the recommendations are changing.  Maybe the prognosis has changed.  Maybe our approach has changed.  Be clear with a family that you are changing your recommendation, approach or prognosis.  This can certainly happen for very young children who are getting cochlear implants.  There are many things we do not yet know about children who receive implants at the age of 12 months, so sometimes that means we end up changing things that we initially talked with the parent about, and that is okay.  There just needs to be a clearly communicated reason.

Monitoring the child's progress is very important.  It is essential to determine change and future intervention, so we definitely want to monitor the children closely, both from a communication standpoint as well as from an audiological standpoint.  That is the way we know the child is achieving the goals we have set or if we need to make some changes in any of the approaches that we are using.  Additionally, if their syndrome or condition is changing, that is another reason we might re-evaluate the methods and techniques that we use with a particular child.  That can help us to work with them long term.


Success can be so very individual for each child.  Defining “success” may be difficult sometimes for children with additional disabilities.  Seeing change may take several months and even years of therapy and intensive training with family and therapists.  Success can have a wide range of skill levels from one child to another.  What may be a goal for one particular child with a syndrome may be different from another child with that exact same syndrome.

Looking at individual success is very important.  It is also imperative to help families identify success, because it is definitely the result of that family's hard work and their dedication to their child and their decision.  Feeling the success encourages the family to continue on this journey and to be consistent with their device.  It helps them to identify more progress that their child is making and keeps them from getting discouraged.

Individual success can be things like improved sound awareness over what they had with their hearing aids.  It can be an ability to be part of the family or to interact more with family members, both verbally and nonverbally.  It can be an increased ability to respond to environmental sounds and even sometimes recognize those environmental sounds. There may be increased attentiveness to the caregiver's voice.  Maybe now the child responds more when mom is talking or when dad is reading a book.

Working Together

Increased focus or connection to the environment and overall improvement in the communication abilities is a huge victory.  In order to achieve these milestones, it is very important that we work together, not just with the family, but with other professionals.  This is the only way for us to get the best possible plan for each individual child.  Different professionals bring different areas of expertise to the discussion.  Management discussions amongst team members initiate creative ideas in tests or therapy techniques to help meet the needs of a particular child.

When we do that, it is helpful to discuss ideas and techniques in one setting that may transfer to another.  Maybe the speech pathologist has found something that is helping them to get the most out of that particular child during therapy.  How can we transfer that same kind of idea into the audiological setting, into programming and into testing? 

It is also helpful when one particular member of the team starts to be concerned that they are seeing an atypical behavior in a child to be able to have meetings and talk with other professionals that can validate those observations and say, “I'm seeing that same thing, too.”

Multiple pairs of eyes observing a behavior is better than one.  Staffing meetings about patients gives fresh perspective on the approach that is being used with the child.  You can talk about things you are seeing in different appointments to help create the best possible plan.  Celebrating the success of a child within the team can help identify strategies that may work with other children and provides encouragement and reinforcement for the team members that what they are doing is working.  Most importantly, it helps that child reach their individual potential. 

Case Studies

Holly Whalen: After presenting this information, we wanted to provide you with a couple of cases that we have seen.  This first one is actually my favorite patient to talk about because it definitely opened my eyes to cochlear implants and children with other special needs.

The first case was a child born with CMV.  She did not pass her newborn hearing screening, and at follow-up, her diagnostic ABR showed no responses.  She had cortical blindness, a swallowing disorder, a seizure disorder requiring medication and quite an extensive time period trying to get the medication appropriate for the number of seizures she was having.  She had global developmental delay, but the most amazing thing about seeing this patient was her parents.  They had very appropriate expectations at the time of the implant candidacy evaluation.  We met with other professionals and the neurologist was unsure if this child had any awareness of the outside environment.

The parents understood that opinion, but still wanted to proceed with the cochlear implant knowing this may provide her with no benefit.  She was implanted at 12 months of age.  At the initial stimulation, the parents were so very excited to see responses, but again, they understood that we were not positive of what would see at that point or if any responses would be long lasting.

After months of therapy, consistent device use and hard work on behalf of the parents, this particular child will calm and soothe by mom's voice and singing if she gets overstimulated or upset.  Mom has a way now to calm her down and relate to her child that she never had before.  They were absolutely thrilled with the outcome of the device, but the reason they were able to be thrilled was because they had very appropriate expectations of what possibly could happen.

This child wears her device consistently.  She becomes upset when it does not work.  They actually use her personal audio cable to connect to music for her as well, and she even alerts to some sounds.  She is not as consistent with some sounds, but her parents definitely feel like the awareness is there.  They were very pleased with their decision and the outcome of it.

Melissa Sweeney: The second case is a child whose hearing loss was diagnosed at the age of five months.  This child was born during a time when newborn hearing screening was not mandated, but her parents became concerned with her lack of responses to sounds very early on, so they requested a hearing test.  She was identified and fit with hearing aids at the age of six months.  She was immediately enrolled in multiple support services including physical therapy and occupational therapy.  Her parents did quite a bit of research on communication modes.  They selected the auditory-verbal approach and started seeing a therapist on a regular basis.

At that time, of course, she did not have any other diagnosis in addition to her hearing loss.  She was also a toddler at the time when cochlear implants were only approved for children starting at the age of two years.  She did not get an implant until she was two years, eight months of age.

During her candidacy evaluation, there were concerns raised about some of her developmental and atypical behaviors that professionals had been observing.  She did receive a diagnosis at that time of autism.  Once she received her cochlear implant, her parents had appropriate expectations for her, but they also had very high expectations for her.

She continued to be enrolled in therapy.  She was receiving Deaf education in her school placement.  She is now in high school and has progressed very well.  She has excellent spoken language skills, but she continues to require support related to pragmatics.  She does have social skills that are appropriate for a teenager.  For example, she is concerned about what her friends at school or other kids at school may think about her if she is wearing her cochlear implant and an FM system.  She does continue to require some social skill services and does very well. 

You probably notice one commonalty in both of these cases; they both had strong family support and parents who were willing to get the services that they needed.

Thank you so much for having us talk on this particular topic.

Question & Answer

Can you tell me more about what the ESP test is?

Holly Whalen: The ESP is the Early Speech Perception test.  I really like that test, especially for these types of patients because it allows you to break auditory information down into very small amounts of change.

You can look at the lowest level of auditory discrimination, which is by pattern.  You can evaluate if they are able to differentiate a single syllable versus two syllable patterns.  Then it moves up to single objects that correspond with spondee words, and then to a picture board test.  This test is typically for audiologists.  It actually has a standard version and a low-verbal version, but it is useful with so many patients.  I have used it before with children who are visually impaired and auditory impaired and who sign by touching your hand.  They can use the physical objects in the low-verbal version to help condition them to the word that I am using as well.

Do you recommend FM systems for all children with cochlear implants?

Holly Whalen: That is a very hot topic for lots of people and there are different caveats to this.  Generally speaking, yes, FM systems are a good idea for children with cochlear implants.  One thing we recommend before putting an FM system on a child, however, is making sure they are able to tell us whether or not the system is working.  One thing that can be problematic is putting an FM system on a child who cannot tell us if it is working; if the FM system malfunctions or turns off, it causes a larger listening  problem overall.

Another important thing is to look at the child's actual school environment and where that information is coming from.  If they are in an environment where the main information is coming from a teacher and the students around them are not providing information, then that is great time where an FM system can be helpful.  However, if a lot of the information is coming from their peers from discussions or small group settings, FM systems can sometimes be very disruptive.

If a young child is in one play group working on something and the teacher is in the kitchen area talking to another child, it can be a very confusing situation for that child as to where that information is coming from.

How often do you meet as a team to discuss the child’s needs, school achievements and long-term goals?

Melissa Sweeney: As a team, we all meet regularly.  The immediate members of our cochlear implant team, the speech pathologist, audiologist and surgeon, meet weekly.  We extend the meeting on a less-regular basis.  We staff each of the kids together before they get an implant and then we also staff them and discuss them as a group after they are implanted.  As far as bringing in the other professionals, certainly that is individual to the child each child and their specific needs.  There are some cases where we have regular phone conversations with developmental pediatricians and or psychologists because they treat some of the kids on a regular basis and that information is valuable to use.  For professionals who treat children on a less regular basis, like a neurologist or infectious disease specialist, we may have less frequent types of conversation with them.

As far as school personnel goes, we have some written forms that we use for some situations, and we do try to have the teachers or therapists working with the child complete those.  We request the child's IEP and review those regularly so we have an idea of what is being recommended with the school.  There are some children whose schools we talk with more regularly than others, but it is individually handled based on each child and what their needs are at that time.

What is the best physical arrangement for a child’s speech processor?

Holly Whalen: Ideally, we want to have the microphone placement as close to the ear as possible, but there are definitely instances where that child has anatomical issues that prohibit that.  We work with that family to get a placement as close to the ear as possible, but sometimes we have to be a little bit inventive in where we are placing it, whether it is on the shoulder, the top of a collar of a shirt or strategically placed in a headband.  We just have to do the best we can.


Centers for Disease Control and Statistics. (2012, October).  Determining how many children have hearing loss.  Retrieved from:

Johnson, K. C. & Wiley, S. (2009).  Cochlear implantation in children with multiple disabilities. In L. S. Eisenberg (Ed.), Clinical management of children with cochlear implants. San Diego: Plural Publishing.







Industry Innovations Summit Recordings Available

Holly Whalen, AuD, CCC-A

pediatric cochlear implant audiologist

Holly S. Whalen, Au.D., CCC/A, is a pediatric cochlear implant audiologist at the UT Dallas/Callier Center which is a member of the Dallas Cochlear Implant Program, a collaboration of UT Dallas, UT Southwestern, and Children’s Medical Center.  Dr. Whalen has provided evaluations and treatment for children with hearing loss including those with additional diagnoses for the last 5 years.  She also provides education and training for doctoral students in the field of audiology.  She has provided training for professionals around the State of Texas.

Melissa H. Sweeney, MS, CCC-SLP, LSLS, Cert. AVT

Cochlear Implant Program Manager

Melissa H. Sweeney, MS, CCC/SLP, LSLS Cert AVT, is the Cochlear Implant Program Manager at the UT Dallas/Callier Center which is a member of the Dallas Cochlear Implant Program, a collaboration of UT Dallas, UT Southwestern, and Children’s Medical Center.  Mrs. Sweeney has provided evaluations and treatment for children with hearing loss and their families for more than 11 years.  She also teaches graduate level classes.  She has served in appointed positions for the Texas Speech-Language-Hearing Association.  She has provided training and workshops for professionals and parents throughout Texas.

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