1. Cochlear Implants: An Overview for School Speech-Language Pathologists Theresa Nicholls, M.C.D., CCC-SLP Assistant Professor of Clinical Communication Disorders Speech-Language Pathology LSU Health Sciences Center tnicho@lsuhsc.edu 504-568-4335 July 14, 2014

2. WHAT IS A COCHLEAR IMPLANT? Electronic prosthetic device Surgically implanted in the scali tympani of the cochlea Bypasses damaged hair cells in the cochlea Electronically stimulates auditory neural elements that do not respond to acoustic stimulation with hearing aids

3. BASIC COMPONENTS External Microphone Speech Processor Battery Component Coil/transmitter Receiver/Stimulator Magnet for Retention Implanted Electrode array

4. HOW DOES IT WORK? External microphone converts incoming sound into electrical signal Speech processor converts electrical signal into a digital code (speech processing strategy) Signal is transmitted across the skin http://bit.ly/CIcomponents

5. CURRENT TRENDS Miniaturization Compactability Splash Proof technology/Water Resistance Wireless Connectivity Remote Controls Flexible Programming/Telemetry measures Music/Telephone/Noisy Environments Accessory and FM adaptability Enhanced Battery Life Bilateral Cochlear Implants Brain set up to hear from two ears Localization Most kids have bilateral implants now Expansion of Candidacy Criteria Muliti-handicapped children are being implanted

6. Most Current Cochlear Implants Offered in the United States Advanced Bionics Med-EL RONDOOPUS 2

7. Cochlear Americas The Nucleus 6

8. PEDIATRIC CRITERIA AGE: 12 MONTHS TO 24 MONTHS Profound sensori-neural hearing loss in both ears No medical contraindications Lack of auditory skill development Appropriate family expectations/motivation Early intervention/therapy in place Early implantation/better prognosis

9. CANDIDACY CRITERIA 25 MONTHS TO 18 YEARS Severe to profound sensori-neural hearing loss in both ears No medical contraindications Monosyllabic word scores of 30% or less in best aided condition Appropriate expectations/motivation

10. MAPPING Term utilized for programming external device Occurs approximately 3 to 4 weeks after surgery Laptop computer utilized Objective measures utilized Progressive maps When they are initially turned on Come back a few times to get bumped up a little each time so its not too loud when they first hear Plateau/stabilization They get used to each Regular maintenance schedule http://www.bing.com/videos/search?q=inital+cochlear+implant++amp ping&FORM=HDRSC3#view=detail&mid=6556C537CDC923DF4B87655 6C537CDC923DF4B87

11. PREDICTIVE FACTORS Medical conditions Communication strategies Language development Mode of education Family support/dynamics Developmental delay Adolescents – poorer prognosis Variability exists Best time to get impants is before the first birthday

12. TEAM APPROACH Surgeon Audiologist Auditory Verbal Therapist Speech/Language Pathologist Nurse/O.R. Staff Educator Early Interventionist Coordinator/Case Manager Administrative

13. Communication, Communication, Communication You and the audiologist will work together to get the best program for your student. You can help with ease of programming and adjustment to new programs with young children. You provide valuable information to the audiologist about your student’s functional use of his/her implant.

14. Adjusting to the Cochlear Implant You are usually on the “front line”. Advising parents about saturation. Talk about realistic expectations. You provide lots of encouragement and education!!! Pointing out the gains in auditory skills that you see. Letting them know what is typical “tolerance issues”.

15. Yes! SLPs Need to Know Pre-CI Audiograms are Important Always get most the most updated audiogram!!!

16. FREQUENCY IN HERTZ (Hz) 125 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 dB HL NR

17. How does speech relate to the audiogram? ACOUSTICS … Remember that class?

18. FREQUENCY IN HERTZ (Hz) 125 0 10 20 30 40 50 60 70 80 90 100 dB HL Fundamental Frequency of most Adult Males

19. FREQUENCY IN HERTZ (Hz) 250 0 10 20 30 40 50 60 70 80 90 100 dB HL Voicing Cues Fundamental Frequency of most females and children’s voices Low Harmonics for Adult Males Nasal Murmur 1 st Formants-High Back/High Front Vowels

20. FREQUENCY IN HERTZ (Hz) 500 0 10 20 30 40 50 60 70 80 90 100 dB HL Primary Cues-Manner Harmonics-Most Voices Formant Transitions- Semivowels /l/ & /r/

21. FREQUENCY IN HERTZ (Hz) 1000 0 10 20 30 40 50 60 70 80 90 100 dB HL Additional manner cues Harmonics of most voices 2 nd formants-nasals 2 nd formants-back/central vowels Plosive burst 2 nd formant transitions- semivowels

22. FREQUENCY IN HERTZ (Hz) 2000 0 10 20 30 40 50 60 70 80 90 100 dB HL Primary cues-place Additional cues-manner Harmonics-most voices 2 nd formant transitions of front vowels Affricate & plosive noise bursts Fricative turbulence 2 nd formant transitions- /l/&/r/

23. FREQUENCY IN HERTZ (Hz) 4000 0 10 20 30 40 50 60 70 80 90 100 dB HL Secondary Cues-Place Upper range of harmonics- most voices 3 rd formants – most vowels Noise burst-plosives & affricates Turbulence of fricatives- important for /s/!

24. FREQUENCY IN HERTZ (Hz) 8000 0 10 20 30 40 50 60 70 80 90 100 dB HL Turbulent noise of all fricatives and affricates

25. FREQUENCY IN HERTZ (Hz) 125 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 dB HL C C C C C C

26. FREQUENCY IN HERTZ (Hz) 125 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 dB HL C C C C C C

27. Remember!!!! Every student is different and comes to you will a diverse background (language, social environment, hearing, personality, family).

28. Keep in mind that a your student’s ability to receive the sounds of speech is only the first step…….

29. Developing Spoken Language Spoken Language AuditionLanguageSpeech

30. Cochlear Implants in the Classroom Classroom Acoustics Reverberation Background noise Distance Sound to Noise Ratio FM Systems Personal and Soundfield

31. Why do we address auditory skills in therapy? In both children and adults, we use it to fully develop their use of available sounds. In children, effective listening becomes their foundation for the development of spoken language.

32. Auditory Skills? You need to know where your student’s auditory skills fall in the hierarchy. Each therapy session will be diagnostic in nature.

33. Basic Stages of Auditory Development Comprehension Identification Discrimination Detection

34. The awareness of whether a sound is present or not present Detection activities should be… Motivating Simple and quick Age appropriate Varied http://www.youtube.com/watch?v=N0Y5putV534&index=66&list=PLiI3ML FN_s_kZuDCoeBInAXGFk3OLUbBy

35. Discrimination Distinguishing differences between sounds The listener's ability to tell whether two sounds are the same or different.

36. Keep in mind the Acoustic Contrasts within the Discrimination Task From Easiest to Most Difficult Suprasegmentals Syllable Length -3 things ones short, medium, long 1 syllable, 2, then 3 Vowel Differences (bat, bet, boot) Manner of Production Differences (t vs. sh) - tea, she, me, lee Voicing Differences ( p vs. b) - boat, coat, Place of Production Differences (k vs. t) -tea or key

37. Identification A person's ability to recognize a sound and then label it.

38. Comprehension A person’s ability to understand the meaning of the spoken message This level requires that the person have a certain degree of semantic and syntactic language development http://www.youtube.com/watch?v=22S8j05ahEI

39. Always keep in mind the variables that affect how challenging a therapy task is for your client.

40. What is your Listening Set? Closed Bridge Open

41. Incorporating Listening Therapy Into Traditional Language Therapy Listening environment Acoustical Highlighting Slow rate Put a space before Make it the last word Content Linguistic Complexity

42. Acoustical Highlighting “Auditory Space” Target Position Rate Background Noise

43. What are the contents of your set? Keep in mind…. The familiarity of the vocabulary How the items acoustically contrast each other The number of key words being used and where they are placed The linguistic complexity of what you are presenting

44. How are you presenting the stimulus items? What is your rate of speech? Are you using acoustic highlighting? Is there background noise?

45. Integrating Listening Goals into Language Goals The progression of normal language development should be followed. Take into account the discriminating abilities needed to learn the new language structure.

46. Ling 6 Sounds What are they? Why do I need to use them? When do I use them?

47. Ling 6 Sound Test OO EEAH SSHMM Also….absence of sound

48. Transitioning Between Visual and Auditory Auditory Information Visual Clarifier Auditory Information

49. Sound-Word Associations These are used to teach the skill of listening to the younger child. They differ greatly in terms of duration, intensity and pitch. Many of these associations are commonly used in traditional, early language therapy. Once the child learns the associated sound then the true word is given.

50. Some Examples of Sound-Word Associations Up, up, up, weeee Mooooo Ahhhhhhhhh (rising and falling intonation) Listening for Littles,1997

51. When they don’t get it the first time…. Acoustically highlight the key word Model a similar question with another person Use familiar information and vocabulary to introduce words Use descriptions

52. Sneaking Language into Auditory Activities AuditoryLanguage Manner of production differences: final position Plural –s marker Auditory memory for three critical elementsVerbs, Prepositions, Nouns Syllable Length Adjectives, Negative Marker Question comprehensionWh- questions Comprehension of several critical elementsStory Retelling within a known context

53. Therapy Materials and Ideas Wind-up toys Stamps Craft activities with pictures Matching pictures Fishing games Memory games Play farm Hiding toys

54. Lots of great stuff is on the internet now!!!!!! Therapy Materials http://www.cochlear.com/wps/wcm/connect/us/for-professionals/re- habilitation/rehabilitation-hope/rehabilitation http://www.cochlear.com/wps/wcm/connect/us/for-professionals/re- habilitation/rehabilitation-hope/rehabilitation http://www.cochlear.com/wps/wcm/connect/64666766-c7e8-47cd-8984- 5f2fc3107e6f/product_cochlearimplant_rehabilitationresources_earlyintervention_lis tenlearnandtalk_en_1.93mb.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=64666 766-c7e8-47cd-8984-5f2fc3107e6f http://www.cochlear.com/wps/wcm/connect/64666766-c7e8-47cd-8984- 5f2fc3107e6f/product_cochlearimplant_rehabilitationresources_earlyintervention_lis tenlearnandtalk_en_1.93mb.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=64666 766-c7e8-47cd-8984-5f2fc3107e6f http://www.advancedbionics.com/us/en/support/tools_for_schools.html http://www.medel.com/int/show2/index/id/284/showdir/Ling_Six_Soundcards http://www.medel.com/us/soundscape/

55. Free On-line Training/Books http://hope.cochlearamericas.com/online-courses http://www.advancedbionics.com/us/en/professionals/trainin g_library.html http://www.advancedbionics.com/us/en/professionals/trainin g_library.html http://www.medel.com/e-learning/ http://s3.medel.com/downloadmanager/downloads/bridge_u s/Resources/en-US/Handbook_for_Educators.pdf http://s3.medel.com/downloadmanager/downloads/bridge_u s/Resources/en-US/Handbook_for_Educators.pdf http://www.deaf- kids.org/IND/documents/CochlearImplantInformation.pdf http://www.deaf- kids.org/IND/documents/CochlearImplantInformation.pdf

56. Example Auditory Objectives for Newly Implanted 1.Accurately imitate Ling 6 sounds with from a 1 foot distance. 2.Accurately imitate Ling 6 sounds from a 3 feet distance. 3.Accurately imitate Ling 6 sounds from a 6 feet distance. 4.Accurately discriminate between three stimuli varying in duration, strength, rhythm and/or intonation. 5.Accurately discriminate among a word versus a phrase versus a sentence. 6.Accurately discriminate common phrases and commands. 7.Demonstrate participation with nursery rhymes and repetitive songs. 8.Demonstrate an auditory memory for sounds through imitation of speech and sound word associations during play.

57. Example Receptive Language Objectives (newly implanted) 1.Target five new vocabulary words a week. These will include a variety of language forms in order to provide a good vocabulary base for sentences. 2.Develop accurate comprehension of simple question forms: “What’s that?”, “Where is Daddy?” 3.Develop comprehension of early prepositions (on, in, out, under, off, up, down). 4.Develop understanding for action words in pictures. 5.Demonstrate understanding for several pronouns (me, mine, your). 6.Demonstrate understating for simple descriptive words (big/little, wet/dry, soft/hard). 7.Demonstrate understanding for part to whole relationships. 8.Demonstrate understating for the “not” marker in simple phrases.

58. Example Expressive Language Objectives (newly implanted) 1.Demonstrate use of words and simple phrase approximations to express needs, wants and to comment on objects. 2. Demonstrate use of simple questions formats. 3.Demonstrate use of word combinations such as (noun + verb, verb + noun, noun + verb+ location, noun + verb + adjective) 4.Answer simple “what” and “where” questions 5.Answer basic yes/no questions.

59. References Foundations of Aural Rehabilitation, Second Edition, Tye-Murray, N. Singular Publishing Group, Inc., 2004. Introduction to Aural Rehabilitation, Fifth Edition, Nerbonne, M., Schow, R., Allyn and Beacon, 2007. The Source for Children with Cochlear Implants, Ertmer, D., LinguiSystems, 2005 Listen, Learn and Talk, Cochlear Corporation The Baby is Listening, Estabrooks, W., Marlow, J., AG Bell Association, 2000. Bringing Sound to Life, Koch, M., Advanced Bionics, 1999. Davis, R., Nicholls, T. Managing Cochlear Implants: Utilizing Your Existing Skills and Knowledge. Louisiana Speech-Language and Hearing Association Annual Conference, Lafayette, LA.