1. Children with Cochlear Implants:
The Freedom Cochlear Implant:
fully integrated into the world of
Another Innovation from Cochlear
hearing –
how and when?
Monika Lehnhardt PhD
Varese, April 8th, 2006

2. Vis ion
In 20 years, an implant will
be the treatment of choice
for anyone with a hearing
loss greater than 50 dB
Dr Jay Rubenstein
March 2004

3. "90% of children with a CI will be
successfully integrated into mainstream
kindergarden and schools, provided they do
not have an additional handicap and they
get adequate rehabilitation with family
support".

4. Step 1: Is there a hearing loss?
Neonatal Hearing
Screening
Programmes

5. Accurate diagnosis

6. Neonate’s response to sound
DeCasper &
Fifer (1980)
Spring and Dale
1977
Eimas et al
(1971, 1979)

7. Infant vocalisations
Stoel-
Gammon &
Otomo,
1986
Kent, et al
1987

8. The Window of Opportunity

9. Sharma et al, 2002
Ear and Hearing, December 2002

10. Sharma et al, 2004
450
400
350 13 month old recipient
P1 latency, ms
300
250
200  At CI activation
150
100 1 week post CI
50 Normal limits 1 month post CI
0
0 5 10 15 20 25 30  3 months post CI
Age  12 months post CI
350
300
P1 latency, ms
250
200
14 month old recipient
150
100
50
Normal limits
0
0 12 24 36
Age
Archives of Otolaryngology – Head & Neck Surgery,
May 2004

11. Categories of Auditory Performance
ref: P Govaerts, C De Beukelaer et al., Neurotology and Audiology 2002
(Antwerp)
Children with normal hearing
use of telephone
discrimination of speech sounds
response to speech sounds

12. Govaerts, et al. 2002
Age at Mainstream Integration
100
Percentage of children
80 Age at
implantation
60 Under 2 yrs
40 2 to 4 yrs
20
0
0 3 5 7
Age (in years)
Otology & Neurology, vol 23; 2002

13. Maree Doble: PhD thesis in progress (University of Sydney)
8 Children, Age of Implantation 8-16 months, enrolled in an AVT program.
Language Speech
First words ⇒ All vowels and consonants
2- 5 months post activation developing along “normal”
expectations ⇒ 18 months
Grammatical development post activation.
⇒ within normal range @ 2 Again, ahead of their
yrs post activation “Hearing Age” but delayed
Standard assessments compared to their
⇒language scores ahead Chronological Age
of their “Hearing Age” but
delayed compared to their
Chronological Age

14. Geers (2004)*
Geers, et al (2003)**
*Archives of Otolaryngology- Head and Neck Surgery, May 2004
*Ear and Hearing, February 2003

15. PPVT
7
Manuel
"Peabody" age (years)
6
5
4
Manrique, et
3
2
al (2004)
1
0
0 1 2 3 4 5 6 7
Chronolgical age (years)
Reynell
7
"Reynell" age (years)
6
>2 yrs 5
4
3
2 to 6 yrs 2
1
0
0 1 2 3 4 5 6 7
Chronological age (years)
Laryngoscope, August 2004

16. Svirsky, et al (2004)
Average Language Development
84
Expressive Language Age
72
60
(months)
12-24 months
48
25-36 months
36
37-48 months
24
12
0
0 12 24 36 48 60 70 84
AGE (months)
Audiology and Neuro-Otology, vol. 9, 2004

17. children
Language development
The deafened
child is
“at risk” for
listening
& spoken
language
skill development
M. Svirsky et al Am. Psy.J.
2000

18. Speech Intelligibility, Svirsky et al.
"The inability to speak intelligibly is a major impediment to
integration in mainstream society for many deaf children".
Normal hearing children have 25% intelligible speech at the age of
18 months and 75 -100% at the age of 36 months.
Is there a sensitive period for CI communicative outcomes?
Earlier CI results in earlier development of speech intelligibility
shows a
developmental trajectory Analysis: the curve moves into the right
direction, i.e. "younger do better".
For the children < 2 y.o. there is a 20% slope improvement, i.e. in
5 years their speech will be totally intelligible.
For older children there is only 9% of slope improvement.
The sensitive period starts at 24 months. "

19. Int J Audiol. 2005 Jul; 44(7): 400 -7.
Paediatric cochlear implantation: the views of
parents
Interviews with 216 families of children
who were implanted at the Nottingham
Paediatric Cochlear Implant Programme
between 1989 and 2002.
"the biggest area of contention is in
respect of their child's education".

20. Laryngoscope.2004 Sep; 114(9): 1576-81.
Outcomes and achievements of students who grew up
with access to cochlear implants.
27 prelinguallydeaf young adults who received a CI at
the University of Iowa between the ages of 2 and 12
years
participated.
•Speech perception and production scores were
highly correlated. Achievement test results indicated
that scores
were within 1 SD from normative data based on
hearing individuals.
•Over 50% of the college-age eligible students
enrolled in college.
•The cohort that uses the CI full-time compares
favourably with their hearing peers on academic
achievement measures.

21. Pediatr Clin North Am. 2003 Apr;50(2): 341 - 61.viii.
Cochlear implantation update
Francis HW, Niparko JK
"Early identification of hearing loss, early hearing aid
use and language intervention, and cochlear
implantation
by 2 years of age are positive predictors for language
acquisition that can approach the levels of normal-
hearing
children.
These are early indications that increased access to
mainstream education and gains in quality of life are
long-term benefits that render cochlear implantation a
cost-effective intervention.

22. Ear Hear. 2003 Jun;24 (3): 236 - 47.
Exploring the language and literacy outcomes of pediatric
cochlear implant users. Spencer LJ, Barker BA, Tomblin JB
"In this study in Iowa 16 peadiatric CI users' language
and literacy skills were evaluated and then compared
with a reference group of 16 age-matched,normal-
hearing children.
•The results show, that children with CI performed
within 1 SD of the normal-hearing, age-matched
children
on measures of language comprehension, reading
comprehension and writing accuracy.
However, the children with CI performed significantly
poorer than the children with normal hearing on the
expressive "Sentence Formulation" subtest, they also
produced fewer words on the written narrative task."

23. Br J Audiol. 1998 Oct; 32(5): 295-300.
Educational placement of deaf children following cochlear
implantation. Archbold S, Nikolopoulos TP, O'Donoghue GM,
Lutman ME.
This study from Nottingham examined the educational
placements before cochlear implantation of 121
children,
and the educational placements two years after
implantation, of the 48 children who had reached that
stage.
•It compared the educational placements of those
given implants prior to schooling,and those given
implants
when already in an educational setting.
•53% of children who were in pre-school at the time of
implantation were in mainstream schools two years
after
implantation, whereas only 6% of those who were

24. The Canadian Model
•Trends toward mainstreaming vary from province to province and are
dependent on numerous factors.
•Over the last two years there has been a growing trend towards
mainstreaming the CI children.
• This tends to occur in provinces where mandatory new born hearing
screening and early intervention are both encouraged and practised.
• In this environment, many children are no longer accepted as a candidate
for a CI unless they provide evidence that they are enrolled and actively
involved in an ongoing aural rehabilitation program prior to and following
surgery.
•There tends to be a natural progression toward mainstreaming for these
children.
•Estimate of mainstreamed children would be as high as 75-80%.
•The trend to encourage oral communication / auditory verbal approaches to
rehabilitation across Canada, is largely due to the teachings of many
prominent professionals in the AV world, among them, Warren Estabrooks,

25. 92% mainstreamed at the Hear and Say
Centre, Australia
This case control study with longitudinal design and repeated
measures investigated the rate of speech and language
development of 29 children with hearing loss (aged 2-6 years,
mean pure tone average loss = 74dB HL in the better ear)
educated using an Auditory-Verbal approach. Results on a
battery of standardised speech and language tests administered
at the start of the study and then 9 months later were compared
to those of a control group of hearing children matched for
language age, gender, intellectual ability and socio-economic
level. There were no significant differences in rate of progress
between the children with hearing loss educated using the
Auditory-Verbal approach and the hearing children on all
standardised assessments (p = <0.001). This research will now
be extended longitudinally.
Outcomes of an Auditory-Verbal Program for Children with Hearing Loss:
A Comparative Study with a Matched Group of Hearing Children
Dimity Dornan
School of Health and Rehabilitation Sciences, University of Queensland, Australia
Hear and Say Centre, Brisbane, Australia

26. Schüler im gemeinsamen Unterricht 1994 – 2004
Land Schulen Integration 1994 Integration 2004 Veränderung
1 Baden-Württemberg 13
2 Bayern 10 9,18% 25,22% 16,04%
3 Berlin 3 42,40% 43,21% 0,81%
4 Brandenburg 1 21,72% 34,86% 13,14%
5 Bremen 1 9,75% 46,61% 36,86%
6 Hamburg 1 kAm 20,50% kAm
7 Hessen 4 14,73% 35,22% 20,49%
8 Meckl. - 1 (+1) 33,25% 48,41% 15,16%
Vorpommern
9 Niedersachsen 5 kAm 35,30% kAm
10 Rheinland-Pfalz 3 4,95% 30,27% 25,32%
11 Saarland 1 20,85% 41,29% 20,44%
12 Sachsen 3 21,64% 40,00% 18,36%
13 Sachsen-Anhalt 2 kAm 40,60% kAm
14 Schleswig-Holstein 1 kAm 14,63% kAm
15 Thüringen 1 27,40% 69,67% 42,27%
16 Durchschnittswert3 49 kAm 38,38% kAm

27. Kinder mit CI ohne Zusatzbehinderung und fremde Muttersprache
und ihr Anteil in den verschiedenen Schulformen (n= 251)
30
30 30
25
23 23
22
20
18
Ges am t
15
0 bis 2:12
14 14
10
8
5
4 2 3
1 1 3 3
0 0
0
ule hu
le Hg S p
as
s e ig a iga ig a ru n
g
ch sc fü r f ür l e lk rK e rk de
e ls ufs le ul e o rk eg ve nd fö r
eg r hu h V R a ti So
R Be S c Sc eg
r rü h
In t F

28. Institutionelle Förderung (n=372)
11% 3% 4% Regelschule
2%
1% Schule für Hg
1% 22% Schule für Spb
Sonstige Schulen
Regelkiga
Sonderkiga
Integrativer Kiga
39%
17% Vorklasse
Frühförderung

29. Institutionelle Förderung
Implantationsalter: 0-1 (n=12)
70%
10% 10%
10%
Frühförderstelle Regelkiga
Sonderkiga Integr. Kiga
Regelschule Schule für Hg.
Sonst. Sonderschule

30. Institutionelle Förderung
Implantationsalter: 1-2 (n=47)
48%
17%
4%
6%
13% 6% 6%
Frühförderstelle Regelkiga
Sonderkiga Integr. Kiga
Regelschule Schule für Hg.
Sonst. Sonderschule

31. Institutionelle Förderung
Implantationsalter: 2-3 (n=56)
26% 29%
14%
15%
5% 11%
Frühförderstelle Regelkiga
Sonderkiga Integr. Kiga
Regelschule Schule für Hg.
Sonst. Sonderschule

32. Institutionelle Förderung
Implantationsalter: 3-6 (n=107)
59%
12%
6%
4% 10% 6% 3%
Frühförderstelle Regelkiga
Sonderkiga Integr. Kiga
Regelschule Schule für Hg.
Sonst. Sonderschule

33. Institutionelle Förderung
Implantationsalter: 6-8 (n=46)
59%
12%
3%
6% 4% 10% 6%
Frühförderstelle Regelkiga
Sonderkiga Integr. Kiga
Regelschule Schule für Hg.
Sonst. Sonderschule

34. Institutionelle Förderung
Implantationsalter: > (n=
8 47)
4%
30%
66%
Frühförderstelle Regelkiga
Sonderkiga Integr. Kiga
Regelschule Schule für Hg.
Sonst. Sonderschule

35. The Wonderful World of Hearing
Thank You
For Your Attention