Children & Cochlear Implants Psychological Evaluation of Implant Candidates James H. Johnson, Ph.D., ABPP Department of Clinical and Health Psychology University of Florida

Overview and Objectives The focus of this presentation is on the role of the psychologist as a member of the cochlear implant team. While the psychologist may often function as a consultant to the team and may be involved in providing treatment services for children being considered for implants, primary attention will be given to the role of the psychologist in conducting pre-implant psychological evaluations of the child.

Overview and Objectives Here we will highlight – the nature of the pre-implant evaluation process discuss issues raised in these evaluations that may argue against implantation or that suggest the need for intervention prior to receiving an implant. Prior to considering these issues, however, it would seem useful to take a brief look at problems that may result in a need for an implant and the nature of the implant itself.

Functioning of the Normal Ear The ear has three sections; the Outer Ear, the Middle Ear and the Inner Ear. Sound is transmitted as sound waves from the environment. These are gathered by the outer ear and sent down the ear canal to the eardrum.

Functioning of the Normal Ear Sound waves cause the eardrum to vibrate which sets the three tiny bones in the middle ear into motion. These are the Hammer the Anvil and the Stirrup. The motion of these bones cause fluid in the inner ear or cochlea to move.

Functioning of the Normal Ear Movement of the fluid in the inner ear causes the hair cells in the cochlea to move. The hair cells transform this movement into electrical impulses. These electrical impulses are transmitted to the auditory nerve and to the brain where they are interpreted as sound.

Sensorineural Hearing Loss Sometimes normal hearing is impaired due to sensorineural hearing loss. This is a hearing loss where – the bones, eardrum and membranes of the ear are intact but the tiny hair cells that line the cochlea have been damaged. When this happens, the damage to the hair cells does not allow the usual electrical impulses to reach the remaining nerve fibers. The nerve fibers then do not have information to send to the brain. This is often referred to as “Nerve Deafness”,

Causes of Sensorineural Hearing Loss Sensorineural hearing loss can be caused by a number of factors including Genetic factors Injury Illness Natural aging Ototoxic drugs, sometimes used to treat life threatening illness.

What is a Cochlear Implant? A cochlear implant is an electronic device, that bypasses the damaged hair cells of the cochlea and stimulates the auditory nerve directly. IT can provide the child with useful “hearing” and improved communication abilities in the implant user. It is a safe, reliable, and an effective treatment for profound hearing loss in children (and adults).

How do Cochlear Implants Work? Cochlear implants detect sounds via an ear level microphone that sends these sounds to a wearable sound processor. The processor converts these sounds to tiny digital impulses that provide hearing sensations to the user. Some of the newest sound processors are small enough to fit behind a person's ear.

How do Cochlear Implants Work? The electronic impulses from the processor are sent to a coil or transmitter (half-dollar sized) worn externally behind the ear over the implant. The coil sends an FM signal to the implant receiver, located under the scalp. The implant then sends these sound impulses to a number of tiny electrodes within the cochlea (inner ear).

How do Cochlear Implants Work? These signals contain information about the frequency and loudness of speech and other sounds. The responses to these signals are then sent via the auditory nerve to the brain where they are interpreted as sound.

A Fitted Cochlear Implant

The Implant Process Audiological Evaluation Medical Evaluation Assessment of hearing levels Testing with high powered hearing aids Speech and language tests to get baseline Medical Evaluation Assess safety of general anesthesia Imaging to assess suitability of cochlea and auditory nerve; CT or MRI. Rule out other medical conditions that could pose problems Pre-implant Psychological Evaluation Assess for characteristics that might contribute to less than optimal outcome.

The Implant Process Implant surgery – general anesthesia Recovery/Healing – 4 – 5 weeks Activation, Fitting, and Mapping – the child wears the processor the processor is also attached to a computer the clinic computer generates signals at carefully controlled levels the child is asked to indicate: - the quietest signal heard (threshold level) - the loudest comfortable signal heard (comfort level) these two levels are assessed for all the electrodes in the cochlea (20 – 30 in all).

The Implant Process Auditory Training Speech and Language Training Using this information a speech processor program is created which allocates sounds between these two levels. The program mapping sets sounds so they are loud enough to hear but not so loud as to be uncomfortable. The program is fine-tuned during following clinic sessions. This may occur a number of times during the first year. Auditory Training Speech and Language Training

Training is Everything

Typical Indications for Implants Severe to profound sensorineural hearing loss with poor speech recognition. Minimal or no benefit from the use of hearing aids Medically able to tolerate cochlear implant surgery. Realistic understanding of the risks, benefits and limitations of implantation Failure to develop good oral language skills despite consistent hearing aid use and intensive rehabilitative efforts A home and educational environment where oral expression is encouraged and supported

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

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?

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?

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?

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?

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?

Assessing Stress and Coping Is there 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?

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?

Psychological and Behavioral Issues: Implications for Intervention While not meant to be inclusive, listed below are some common examples of psychological and family issues, 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 Issues of Selective Noncompliance

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

“Externalizing” Disorders Psychological disorders that bring the child into conflict with his/her environment can also pose potential problems for children who are implanted. These include problems like ODD/CD.

“Externalizing” Disorders Other childhood externalizing problems would include problems such as ADHD

Issues with Externalizing Behaviors Problems The problem that severe child behavior disorders pose for the child implant candidate are obvious. Children with ODD/CD may display defiant and non-compliant behavior to a degree that necessary auditory and speech and language therapy is difficult if not impossible. Those with ADHD may be unable to benefit from their training due their problems of impulsiveness, inattentiveness and activity level. While displaying such problems may not represent an absolute contraindication for implantation, it seems essential that such problems be brought under control prior to receiving an implant.

Issues of Selective Noncompliance In some instances the child does not display any specific diagnosable disorder but does show evidence of selective non-compliance. An example might be the child who refuses to wear prescribed hearing aids despite the fact that he/she derives some benefit from them. As this non-compliant behavior may be seen as representing a challenge to implant compliance it may be necessary for the child (and sometimes family) to demonstrate compliance in this area prior to being reconsidered for implantation. Example

CI Evaluation: Overview As can be seen from what has been presented here, pre-implant psychological evaluations are quite similar to evaluations conducted with child transplant candidates. A major difference, being the absence of the major medical stressors that are often associated with the need for transplantation. While there are some instances where psychosocial contraindications are so great that the child is denied and implant, this is typically not the case. In the majority of cases the focus is on identifying problems and addressing them so that implantation is possible.

That’s All Folks! Questions?