Cochlear Implants

1
Cochlear Implants MainstreamingImplications
to Consider

• Irene W. Leigh, Ph.D.
• Department of Psychology
• Gallaudet University, USA
• 2nd Brussels Conference
• Bilingual-Bicultural Education
• 17 October 2008

2
Cochlear Implants and Mainstreaming.

• Do cochlear implants (CI) actually facilitate
  mainstreaming?
• Need to look at two aspects
• Academics
• Psychosocial Adjustment

3
First. CI Expectations?

• Surgical/medical intervention to improve hearing
  (Hintermair Albertini, 2005)
• Early improved auditory access to speech
  information (Geers, 2006 Hintermair Albertini,
  2005)
• Improved spoken language, closer to level of
  hearing peers (Geers, 2006)
• With appropriate family and education
  intervention.
• Integration into hearing society, not set apart
• Deaf children with CI will be normal.

4
Mainstreaming Expectations?

• Educational
• Deaf children with CI will receive an appropriate
  education with hearing peers.
• Deaf children will access classroom information.
• Deaf children with CI will perform equally as
  well as their hearing peers.

5
Mainstreaming Expectations, continued

• Social
• Deaf and hearing children will be friends.
• Spoken language will provide full access to peer
  communication.
• Psychological
• Self-esteem, loneliness, and identity will not be
  problem issues.

6
Current State re CI Mainstreaming

• Implantation rate
• between 50 and 80 in most developed countries
  (Hyde Power, 2006).
• In many, not all countries, children are moving
  from deaf to mainstream education
• (e.g., Angelides Aravi, 2006/2007 Archbold,
  2004 Gallaudet Research Institute, 2006 Geers,
  2006 Hyde, Ohna, Hjulstadt, 2005/2006 Risdale
  Thompson, 2002 )
• Careful selection for mainstreaming in some
  countries based on communication skills
• (e.g., Wauters Knoors, 2008)

7
Burning Research Questions

• Are the ethics of decisions about CI fully
  understood?
• Does the CI raise academic achievement?
• What is appropriate intervention?
• What really happens with socialization?
• What about psychosocial functioning?
• What is the identity of a child with a CI?

8
Ethics of CI Decisions?

• Beneficence (Do good)
• Is the CI of benefit to the child?
• Is the CI a social good? (Hyde Power, 2006)
• Nonmaleficience (Do No Harm)
• Will the CI harm the childs overall development?
• Minuscule chance of medical or technical problem?

9
Ethics, continued

• Autonomy
• Are decisions made freely after unbiased
  information?
• How does informed consent happen?
• 45 of a sample of 121 CI centers (United States)
  included information about Deaf culture, ASL use,
  and identity issues in informed consent forms
  (Berg, Ip, Hurst, Herb, 2007)
• Justice
• Does everyone who could benefit from the CI get
  it?
• Those of certain races socioeconomic status
  more likely to get the CI appropriate help.
  (Christiansen Leigh, 2002/2005 Hyde Power,
  2006)

10
Does the CI raise childrens academic
achievement?

• Reading/academic achievement varies, whether in
  mainstream or deaf setting (Marschark, Rhoten,
  Fabich, 2007, literature review)
• Variability due to confounding variables in
  research
• Also, study participants tend to be motivated.
• Overall benefit academic achievement better with
  CI than without CI, but not equal to hearing
  peers
• Does this improvement continue as children get
  older?

11
What is appropriate intervention?

• Who determines what the childs needs are? What
  are their philosophies?
• Parents? Caretakers? Audiologist /or Otologist?
  Intervention specialist? Education Department?
  Others?
• Child?
• Do interventions match the childs needs?

12
Educational Intervention?

• Mainstreaming or deaf schools?
• Look at expectations for academic achievement and
  psychosocial functioning
• Do we see the child as a deaf child with a CI or
  as a hearing child who must be mainstreamed?
• What is reality of childs situation? Childs
  needs?
• Easy to overlook impact of missed information,
  noisy environment, etc.
• Example If child with CI is academically strong
  but weak in spoken language, then what placement
  is best? What intervention is best?

13
Research on Educational Placement?

• Effect of CI on educational placement not clear
  (Marschark, Rhoten, Fabich, 2007, literature
  review)
• Assumption that CI mainstream
• Most stay in the mainstream
• But various studies show movement between
  mainstream and school for the deaf placement,
  depending on child.
• Mainstream not the answer for every child with CI

14
Appropriate Intervention in Language Choice?

• Push for either-or versus both in parent
  communication choice (Hintermair Albertini,
  2005)
• Most choose spoken language, but many value
  bilingualism
• Parents often pragmatic, add signed languages,
  particularly before implantation (approx lt 50)
  (Christiansen Leigh, 2002/2005 Watson, Hardie,
  Archbold, Wheeler, 2008 Zaidman-Zait, 2008)
• Children may switch to spoken language even while
  parents are still signing (Watson, Hardie,
  Archbold, Wheeler, 2008). Signing seems to help
  develop spoken language (reports by
  Yoshinaga-Itano).

15
Socialization in the Mainstream?

• Society is responsible for educating children.
• Atmosphere should foster individuality,
  self-image, and collective collaboration.
• Socialization and academic mainstreaming should
  occur in tandem.
• Is social mainstreaming conducive or not for deaf
  children with CI?
• Question of fit between deaf child and mainstream
  social environment?

16
Fit between Child and Mainstream?

• Whole child approach is critical.
• Consider
• Academic standing relative to hearing peers
• Ability to clearly articulate needs through
  spoken language and be understood by hearing
  peers

17
Socialization Mainstreaming Research

• General conclusion for children with CI
• Social well-being is positive
• Christiansen Leigh, 2002/2005
• Parent and deaf adolescent perceptions, using
  interviews
• Spencer Marschark, 2003
• General review
• Percy-Smith et al., 2006
• Parent perceptions
• Socialization improves as communication with
  hearing peers improves
• e.g., Bat-Chava, Martin, Kosciw, 2005 Stinson
  Foster, 2000 Wauters Knoors, 2008 Wheeler,
  Archbold, Gregory, Skipp, 2007)

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But..

• Studies of children with CI playing in groups or
  in classroom discussion with hearing peers
• Ongoing struggle, limited consistent success in
  group interactions (based on observation)
• (e.g., Boyd, Knutson, Dahlstrom, 2000 Knutson,
  Boyd, Reid, Mayne, Fetrow, 1997 Preisler,
  Tvingstedt, Ahlström, 2005) AND (based on
  sociometric measure) (Wauters Knoors, 2008,
  note 9 out of 18 deaf children in their study
  had a CI but CI per se was not studied, all had
  good spoken language).

19

• Many adolescents with CI are comfortable both
  speaking signing, want to associate with both
  deaf and hearing peers, not just with hearing
  peers alone (e.g., Christiansen Leigh,
  2002/2005 Wheeler, Archbold, Gregory, Skipp,
  2007)
• Support for signing provided in co-enrollment
  classes facilitates social interaction (Wauters
  Knoors, 2008).

20
Socialization Message?

• Should not focus only on hearing socialization
• Variability
• Some do well, particularly if they have strong
  spoken language skills.
• Most accommodate or feel rejected.
• Ongoing difficulty, with or without CI
• Importance of deaf peers, including peers with CIs

21
Psychosocial Functioning?

• Parental expectations for children with CI
• CI will facilitate psychosocial adjustment in
  family, school, neighborhood settings.
• Evidence (Bat-Chava Deignan, 2001 Bat-Chava,
  Martin, Kosciw, 2005 Chmiel, Sutton,
  Jenkins, 2000 Christansen Leigh, 2002/2005
  Kluwin Stewart, 2000 Nicholas Geers, 2003a)
• Parents see improved quality of life, greater
  self-esteem, confidence, outgoing behavior
  compared to before CI, even though socialization
  problems with hearing peers still happen.

22
Studies of Children

• 181 children, ages 8-9, 83 mainstreamed, approx
  ½ speech sign, ½ speech (Nicholas Geers,
  2003b)
• Self-report on childs self-perceived competence
• Competent, well adjusted (cognitive, physical,
  socio-emotional, school performance,
  communication)
• Younger children those using most updated
  speech processor gave themselves higher ratings
• Parent report
• Saw children as being well-adjusted.
• Neither outcome was influenced by speech quality,
  language or reading level, communication mode, or
  school placement.

23
Studies, continued

• Effects of CI experience on loneliness (Schorr,
  2006)
• 37 children with CI, ages 5 to 14, 32 in
  mainstream
• All used spoken language fluently
• No overall significant difference between sample
  and hearing norms in reporting loneliness
• Much variability, some do feel lonely
• Older age at implant associated with more
  loneliness
• Message Focus on the person and situation

24
Studies, continued

• U.S. preliminary questionnaire study of 57 deaf
  adolescents with and without CI (Leigh,
  Maxwell-McCaw, Bat-Chava, Christiansen, in
  press)
• 26 out of 28 adolescents with CI in mainstream
  settings, 77 preferred spoken language
  exclusively
• Those without CI (29) mostly in deaf settings,
  only 15 preferred spoken language
• Both groups similar psychosocially
• Self-perception, satisfaction with life,
  loneliness
• Level of loneliness similar to normative sample
• CI users Negative relationship between
  scholastic self-esteem acceptance by deaf peers

25
Identity Issues

• Interview Studies
• Interviews with 29 British cochlear implanted
  young adolescents from both deaf mainstream
  settings (Wheeler, Archbold, Gregory, Skipp,
  2007)
• felt positive about their cochlear implants.
• majority did not demonstrate a strong Deaf
  identity, but identified as deaf
• Swedish interview study of 11 children with CI,
  some in the mainstream (Preisler, Tvingstedt,
  Ahlström, 2005)
• Some see the CI as a natural part of their lives
• Used sign language when had trouble understanding
  
• The authors conclude a bicultural identity is
  better.

26
Identity, continued

• Interviews with 14 mostly mainstreamed adolescent
  and young adult cochlear implant users
  (Christiansen Leigh, 2002/2005)
• Most see themselves as deaf, one as hard of
  hearing.
• Most had both hearing deaf friends, desired
  contact with both deaf and hearing peers.

27
Identity, continued

• Questionnaire Studies
• Israeli questionnaire study of 115 adolescents
  (Most, Weisel, Blitzer, 2007
• 10 of them had a CI
• All exposed to deaf peers either in mainstream or
  deaf classes
• Adolescents with CI more positive attitudes
  than others in family climate, self-esteem,
  communication
• Did not significantly differ in attitudes about
  social status, academic achievements, Deaf
  culture, or identity classification (bicultural).
  

28
Questionnaire Studies, continued

• U.S. study of 45 adolescents with without CI
  (Wald Knutsen, 2000)
• Not clear re percentage mainstreamed
• Both groups similar in Bicultural and Deaf
  identities
• Adolescents with CI had more endorsement of
  hearing-oriented identity.
• U.S. preliminary questionnaire study of 57 deaf
  adolescents with and without CI (Leigh,
  Maxwell-McCaw, Bat-Chava, Christiansen, in
  press) (See Slide 24)
• Most affirmed hearing-oriented identity, but
  number with bicultural identity similar to those
  in deaf settings.

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• Implications for Identity
• CIs are not necessarily creating a body of
  children stuck between the deaf and hearing
  worlds
• They do have a clear identity.
• Most often hearing acculturated or bicultural,
  meaning comfort in shifting identities.

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Critical Points

• Mainstream students do report satisfaction with
  life and positive self-esteem.
• Not everyone suffers.
• Students can be lonely or socially well-connected
  either in mainstream or deaf schools.
• Mainstream students can be comfortable with both
  deaf and hearing peers
• Important Ability to communicate well through
  sign, through speech, or both
• If alone in the mainstream, less chance to learn
  about Deaf identities
• Adolescents with CI needing more socialization
  can find Deaf communities and develop bicultural
  identities.

31
In the end.

• Its not just the CI
• Importance of home communication
• Positively related to scholastic self-esteem,
  social self-esteem, satisfaction with life
  (Leigh et al, in press)
• Its not just school placement
• Importance of good matching between child and
  school
• Internal characteristics
• Environmental support and communication access in
  and outside the classroom