1. Children & Cochlear Implants
Issues in Behavior Management
James H. Johnson, Ph.D.
Department of Clinical and Health Psychology
University of Florida

2. Overview and Objectives
 The focus of this presentation is on the role of
behavior management and other intervention
approaches in the cochlear implant process.
 We will begin by briefly reviewing issues addressed
in the pre-implant psychological evaluation.
 Examples of issues raised in this evaluation, that
may suggest the need for intervention, will be
highlighted.
 Finally, we will consider the nature of approaches to
intervention that may be of value in addressing pre
and post implant issues.

3. The Pre-Implant Psychological
Evaluation
 Knowledge Assessment
 Motivation for Implant
 Family Agreement/Disagreement
 Appropriateness of Expectations
 Challenges to Compliance
 Parent-Child Communication
 Family/Psychological/Behavioral
Issues
 Issues of Stress and Coping
 Questions/Concerns Regarding the
Implant Process

4. Knowledge Assessment
 Do the parents (and child, if older) have reasonable
knowledge of what the implant process involves?
– What surgery will involve and the time necessary for
healing.
– The nature of post-implant activities (e.g., initial
fitting/activation and mapping, auditory training,
speech/language therapy, scheduled follow-ups).
– The need for parental involvement in the child’s therapy?
– What this will require in parental time and effort.
 Have parents gone beyond “passive learning” in an
attempt to obtain information (e.g., internet
searches, making contacts with others who have been
implanted)?
 Any needed information?

5. Assessing Motivation for
Implantation
 Do the parents (and child, if older) indicate a
desire for the implant?
 Have they been active in seeking information
regarding the implant?
 Have they been active in moving the implant
process along?
 Do they show a willingness to do “whatever
is necessary” to make the implant a success?

6. Family Agreement and
Disagreements
 Do parent and child agree on the
desirability of the implant?
 Do both parents agree on the
desirability of an implant?
 Are both willing to be active
participants in the implant
process?
 Do other close family members
support the idea of an implant?

7. Assessing Expectations
 Do parents and child (if old enough) convey an
understanding that children vary in response to
implants?
 Is there understanding that degree of success depends
on parent and child being active participants in the
process (e.g., auditory training, speech/language
therapy, etc)?
 Do they understand that the child may not “hear” the
same way as a non-hearing impaired individual?
 Is there implied acceptance of outcomes that may not
involve;
– the development of functional speech
– a full understanding of speech without speechreading?

8. Challenges to Compliance
 Do parents/child convey a willingness to be an active
participant in the implant process?
 Do they have a plan to deal with practical issues
associated with implantation;
– arrangements for surgery,
– travel to doctor appointments,
– auditory training, speech therapy, etc.?
 Is there a history of keeping appointments, active
participation in prescribed communication
programs, complying with the use of assistive
devices, and dealing with other required medical
treatments?

9. Assessing Stress and Coping
 Isthere evidence of significant family stress?
 What are the nature of existing stressors?
 Do family members have adequate social
supports to assist them in coping with
ongoing stressors?
 Do family members appear to have adequate
skills to cope with existing stressors?
 Considering both the level of stress and
coping styles, is stress likely to compromise a
successful outcome?

10. Assessing Other Psychosocial
Factors
 Do parents appear to show evidence of deficits
that could compromise successful outcome or
require special assistance?
 Does the child show evidence of delays in
development severe enough to compromise
success?
 Do either parents or child show evidence of
psychological/behavioral problems that could
compromise success?

11. Psychological and Behavioral Issues:
Implications for Intervention
 While not meant to be inclusive, listed below are
selected examples of psychological and family issues,
sometimes highlighted in the pre-implant evaluation,
that may warrant family or behavioral intervention.
– Family Disagreement Regarding Implantation
 Parent-child differences
 Parent-parent differences
– Externalizing Disorders of Childhood
 Oppositional Defiant Disorder
 Attention Deficit Hyperactivity Disorder (ADHD)
– Issues of Selective Noncompliance

12. Issues of Family Disagreement
 Sometimes parents have markedly different views
regarding the desirability of an implant.
 In the case of older children or adolescents, parent
and child may have different views regarding the
implant decision making process.
 Such conflicts can potentially represent a significant
challenge to a successful outcome and may, in some
instances, represent a significant contraindication for
implantation.
 In other instances, family based interventions may be
recommended in an attempt to resolve issues prior to
implantation.
Case Examples

13. “Externalizing” Disorders
of Childhood
 Externalizing disorders of childhood are conditions that
are characterized by a constellation of behaviors that
bring the child into conflict with his/her environment.
 Here, we will focus on two such conditions,
– Oppositional Defiant Disorder (ODD)
– Attention Deficit Hyperactive Disorder (ADHD).
 Special attention will be given to these conditions, as
both can pose significant challenges for the child being
considered for a cochlear implant.
 Discussing these conditions also provide a way to
highlight behavior management approaches that can be
useful in dealing with a range of implant related issues.

14. Oppositional Defiant Disorder
 Diagnostic Criteria - A pattern of
negativistic, hostile, and defiant
behavior lasting > 6 months, with four
(or more) of the following present:
– Often loses temper
– Often argues with adults
– Actively defies or refuses to comply
with adults’ requests or rules
– Often deliberately annoys people
– Often blames others for his/her
mistakes or misbehavior
– Is often touchy or easily annoyed by
others
– Is often angry and resentful
– Is often spiteful and vindictive

15. Attention Deficit Hyperactivity
Disorder (ADHD)
 ADHD is a frequently occurring and
chronic, neurodevelopmental disorder
of childhood.
 Symptoms include developmentally
inappropriate levels of activity,
distractibility, and impulsivity.
 Children with ADHD have functional
impairment across multiple settings
including home, school, and peer
relationships.
 ADHD has been shown to have long-
term effects on school performance,
vocational success, and social-emotional
development

16. Treatments of Externalizing
Disorders
 Treatment typically involves
interventions derived from an operant
behavioral model.
 Interventions may involve more general
approaches to teaching parents principles
of behavior modification or more
structured approaches to parent training.
 Behavior management is often combined
with other forms of intervention, with
childhood ADHD being a case in point.

17. The Behavioral Model: Basic
Assumptions and Features
 Abnormal behavior is learned!
 It is learned according the same principles that
govern the acquisition of normal behavior.
 The focus is on one’s social learning history and
on overt observable behavior rather than on
putative internal or “intrapsychic” determinants
of behavior.
 Emphasis is on those factors in the environment
that elicit and maintain problem behavior.
 Much of abnormal behavior can be unlearned.

18. Basic Principles of
Behavior Management
 Approaches for Increasing Behavior
– Modeling/Observational Learning
– Reinforcement
 Positive Reinforcement
 Negative Reinforcement
 Approaches for Decreasing Behavior
– Extinction
– Punishment

19. Modeling/Observational
Learning
 Involves providing the child with models
where he/she can learn new skills by
observing the behavior of others.
 Most useful in teaching new behaviors to
reduce skills deficits - can also be used to
facilitate performance of previously
learned behaviors and to decrease fear
reactions.
 Is usually combined with reinforcement
procedures.

20. Reinforcement: Increasing
Behavior for Better or Worse
 The principle of Positive
Reinforcement states that
behaviors followed by a
reinforcing state of affairs
(rewards) are increased.
 The principle of Negative
Reinforcement states that
behaviors that result in the
reduction of an aversive state of
affairs will be increased.
 Example: At The Grocery

21. Using Rewards to Change
Behavior: Some Basics
 Rewards need to be individualized to the child.
– Some Children don’t like M&M’s and they do melt
in your hand!
 Use a variety of rewards to avoid satiation.
 Rewards should be administered in small units.
 Rewards should usually be administered
immediately after the desired behavior has
occurred.
 If this is not possible, use points or tokens to
bridge the gap between behavior and back-up
reinforcement.

22. Still More Principles of
Reward
 Reinforcers should be exclusively under the
parent’s control.
 Rewards should be practical!
 They should be easily given, not too costly, and easy
to obtain.
 Consistency is everything!
 Rewards should usually be given on a continuous
reinforcement schedule (at least at the beginning).
 After a behavior is well learned you might switch to
a partial reinforcement schedule.

23. Extinction
 Extinction: A decrease in
behavior associated with the
withdrawal of reinforcement.
 May result in the failure of some
desired behaviors to be
maintained.
 Can result in strong emotional
reactions or response “Bursts”.
 Can be used to reduce problem
behavior – Case Example.

24. Punishment
 Punishment: A decrease in behavior
resulting from behavior being
followed by an aversive state of
affairs.
 Punishment can be of the physical
variety, as in example to the right.
 It can involve the loss of rewards as in
a loss of points for inappropriate
behavior in token programs or when
a child is put in “Time-Out”.
 Punishment procedures, when used,
are generally combined with
reinforcement for desired behavior.

25. Using Punishment: Some
Negative Effects
 Used consistently with young children, punishment
results in strong negative emotional responses that
can lead to both avoidant behavior and decreased
levels of attachment.
 Punishment is one way of modeling aggression and
is associated with increased aggressive behavior in
the child.
 Punishment often results in only a short term
reduction in problem behavior.

26. Punishment: Additional
Issues
 Punishment does not teach the child how
to behave – what he or she is supposed to
do.
 Punishment is often not needed, as
alternative approaches, such as
rewarding desirable behaviors that are
incompatible with problem behavior can
often bring about desired results.

27. Child Behavior Management:
Two Approaches
 There are two primary treatment approaches for
working with children displaying oppositional
defiant behavior.
 One can be described as the “Patterson – Living
with Children” Model.
 The second is Parent-Child Interaction Therapy,
developed by Dr. Sheila Eyberg of the
University of Florida.
 Both are “Empirically-Supported Treatments” as
research has consistently documented their
effectiveness.

28. Living with Children Model
 Based on the work of Dr. Gerald
Patterson.
 Involves a therapist working with
parents, teaching basic principles of
behavior modification so they can
effectively modify their child’s
behavior.
 The program focuses on:
– Targeting Problem Behavior
– Increasing desirable behavior
– Decreasing undesirable behavior
– Documenting effectiveness.
– Helping parents become effective
behavioral trouble-shooters in
managing their children.

29. More About the “Living With
Children” Model
 The “Living with Children” Model is less
structured that the Parent Child
Interaction Training Model, to be
described next.
 It can be used with parents of children of
all ages, rather than only those below the
ages of 6 or 7, as is the case with Parent
Child Interaction Training.

30. Parent Child Interaction Therapy
 PCIT is a treatment for children with disruptive behavior
disorders that emphasizes improving the parent-child
relationship and changing parent-child interaction
patterns.
 Parents are taught specific skills to establish a nurturing
and secure relationship with their child while increasing
positive behavior and decreasing negative behavior.
 Treatment is usually carried out in a playroom equipped
with a one-way mirror so the therapist can guide the
parent as he/she interacts with the child.
 Communication between therapist and parent is via a
bug-in-the-ear device where the therapist can actively
coach the parent in how to respond to the child’s behavior
and reinforce the parents in-therapy behavior.

31. PCIT: Stages of Treatment
 In addition to the therapist providing parents with overviews
of different stages of therapy and principles of behavior
management, PCIT involves two stages:
 The first stage is Child Directed Interaction (CDI) where the
focus is on parents engaging their child in nondirective play
with the goal of enhancing the parent-child relationship.
 Here the child is allowed to take the lead with parents
focusing on communication with the child by:
– Praising the child’s behavior,
– Reflecting the child’s statements,
– Imitating and Describing the child’s play,
– Being Enthusiastic,
– Ignoring any negative behavior, and
– avoiding any attempt to lead the play, give commands, ask
questions or give criticism.

32. PCIT: Stages of Treatment II
 Parent Directed Interaction (PDI), where the parent takes a
more active role, is designed to teach parents specific behavior
management techniques for dealing with problem behavior.
 Here, the primary goals are increasing compliance and
deceasing inappropriate behaviors.
 In PDI the parent learns to give clear and direct commands, to
reward compliance, and to use time-out as a consequence for
non-complaint or other disruptive behavior (while continuing
to use elements of CDI between commands).
 Time-out initially involves setting on a chair (3 minutes), with
a Time-out room used as backup, for refusals to stay in the
chair.
 A major focus of therapy is on helping parents learn to use the
skills developed in PCIT sessions in the home environment.

33. PCIT: Final Comments
 PCIT is generally used with children between the
ages of 3 and 6.
 The length of treatment is determined by the length
of time it takes parents to reach criterion in terms of
skills development (usually 12 to 16 session).
 Many controlled research studies have provided
strong support for the effectiveness of this approach.
 Another strength of this treatment is the “hands on
approach” to teaching basic behavior management
skills (reinforcement, extinction, punishment) that
are easily transportable the home situation.

34. Treatment of ADHD
 As children with ADHD often display
disruptive behavior, approaches like
those just described may also be useful
with these children as well.
 However, it is often the case that other
approaches will also be necessary. These
may include:
– The use of medication to treat ADHD
core symptoms.
– Other treatments for comorbid
conditions.
– Educational accommodations to
minimize problems with inattention
and distractibility and problems with
academic achievement.

35. Behavior Management: Other
Areas of Applicability
 The use of behavioral principles discussed
here is not restricted to children with serious
behavior disorders.
 They are also applicable to other situations
where it is desirable to either increase or
decrease specific behaviors.
 One example might include a home-based
reinforcement programs for children who
are non-compliant in wearing hearing aids.
 Clinic based reward programs might also be
useful with children who are poorly
motivated to participate in auditory
habilitation programs, speech therapy, and
other training necessary for implant success.

36. That’s All Folks! Questions?