An overview of the issues in
current practice with young deaf
children with cochlear
implants (CI)
Judy Halden & Julia Divers
The Key Issues
integrated multi-disciplinary
working;
the Monitoring protocol for deaf
babies and children;
signing/speech reading, pre and
post implantation;
The Key Issues, contd.
promoting language development
in deaf children;
access to incidental language for
deaf children;
use of the home language and
the effect of cultural differences.
Purpose of Symposium
To:
voice and share the concerns of
practitioners;
support each other through jointly
exploring current research;
develop and support evidencebased practice;
Purpose of Symposium, contd.
explore collaborative working;
identify areas for further research.
The First Issue
The importance of integrated multidisciplinary working in supporting
families and the
frustrations/diversity of
experience some professionals
have when supporting the families
of implanted children
Responses to Questionnaire
information from the wider team
around the child is not always
exchanged;
it is not always possible to attend all
joint sessions for every child due to
geographical locations;
care pathways and roles are not
always clearly defined;
Responses to Questionnaire,
contd.
personnel can change rapidly
within services;
lack of a „lead‟ professional or key
worker when more than one is
involved;
important to have a „specialist‟ as
the lead professional;
Responses to Questionnaire,
contd.
variation in individual
practitioners‟ attitudes to
collaborative working;
wide variation in multi-disciplinary
working, support and liaison
between Cochlear Implant
Centres and local services;
Responses to Questionnaire,
contd.
employment of private services in
addition to all the other agencies
can sometimes cause conflict.
Universal Principles for Effective
Joint Working
showing mutual respect;
building an effective relationship;
discussing roles and
responsibilities;
sharing information;
working with others;
joint training;
Universal Principles for Effective
Joint Working, contd.
integrating management;
developing protocols;
monitoring the service;
extending collaborative work.
(BATOD/RCSLT, 2007)
Protocols for ToDs and SLTs
Working Together
• referrals;
• family support plans;
• hearing aids/habilitation;
• assessment;
• planning and liaison.
Key Questions
How can we continue to improve
the protocols that already exist to
encompass all agencies working
with the child and their family and
promote their uptake?
Key Questions, contd.
How can we ensure that one
person is identified as having
responsibility for co-ordinating
support services for the child and
their family?
Key Questions, contd.
How can we ensure that training
remains available for practitioners
to become specialists in deafness
and to continue to develop those
specialist skills?
Key Questions, contd.
How can we ensure that families receive
„coherent and consistent support‟ from
„well co-ordinated and seamless
services‟ (National Deaf Children‟s
Society (NDCS), 2002, p.16), with
particular regard to liaison between local
and wider services in terms of multidisciplinary working, advice and support?
The Early Support Monitoring
protocol for deaf babies and
children (2006)
Advantages of the Monitoring
protocol
A „central document‟, which allows:
- families to feel in control
- child‟s progress to be shared
with the professionals
involved with the deaf child and
their family;
Advantages of the Monitoring
protocol, contd.
helps understanding of what
communication is;
enables the child‟s progress in
developing communication skills
to be charted;
Advantages of the Monitoring
protocol, contd.
helps to place progress in the
context of general development;
engenders some feelings of
security.
Limitations of the Monitoring
protocol
Professionals
not all services refer to the
materials;
some services unaware of
document‟s existence;
information not always
disseminated to the wider team;
Limitations of the Monitoring
protocol, contd.
Parents/Carers
document linked to key worker only;
not all families want to complete the
protocol due to:
- time
- other siblings
- reading/language issues
Limitations of the Monitoring
protocol, contd.
prefer to be led by professionals;
feelings of anxiety;
language/cultural barrier;
strategies and ideas not given to
move child forward and attain
listed targets.
Level 2 Materials/developmental
cards
Help parents and families to
understand the importance of
stimulating interaction, developing
the baby‟s phonology and grammar
as well as monitoring these aspects
of their development.
Developmental/‟fridge‟ cards
keep the current focus strategies
in mind;
further support development at
each stage;
give direct advice and ideas for
activities;
Level 2 materials
Intended to facilitate:
interpretation of what the
information gleaned from the
Monitoring protocol means;
discussion around reassuring
parents that their child is moving
forward appropriately;
Level 2 materials, contd.
promotion of appropriate
strategies that could be taken if
progress is not as expected;
provision of a snapshot or
cumulative look at particular
areas of development that may be
at risk.
Key Questions
How can we increase the
likelihood of professional
agencies sharing information
generated by the Monitoring
protocol?
Key Questions, contd.
How can we support parents in
their full understanding of the
Monitoring protocol and
encourage them to share the
information with all agencies
involved with the child?
Key Questions, contd.
How can we ensure that all
agencies involved with the child
and their family are conversant
with all the Early Support
materials?
Advice to parents regarding
signing/lip reading, pre and
post implantation,
and the influence this has on
the child’s access to
incidental language
“Cochlear implantation provides
the potential for incidental learning
through natural consequences in
the environment to a degree that
may not be possible with hearing
aids. Helping implanted children
realise this potential, however, is
one of the greatest challenges
facing clinicians”.
(Robbins, et al, 2000)
Respondents‟ Comments
Greater degree of flexibility required,
in relation to visual communication,
dependent upon the individual needs
of each child and their family;
access to incidental language
supported through a range of visual
cues;
Respondents‟ Comments,
contd.
only 60% of respondents
commented on strategies used to
encourage access to incidental
language.
Key Questions
Does research suggest that the
development of the auditory
pathway will be compromised if
visual cues are not removed?
Key Questions, contd.
If research has demonstrated that
the stimulation of the auditory
pathway is wholly dependent on
removal of all visual cues, how do
we make the transition less
traumatic for both the child and
the family?
Key Questions, contd.
If we do not encourage the
development of the child‟s ability
to access visual cues from the
outset, what impact might this
have on their access to incidental
language and on their social and
emotional development, if any?
Key Questions, contd.
Should we as practitioners be
focusing more closely on
encouraging families to both
recognise the need for and
develop strategies to promote
access to incidental language?
Promoting language
development in deaf children
Parent‟s Questions
„Can my baby hear anything?‟
„How will I communicate with my
baby?‟
„Will my child be able to
understand me?‟
„Will we need to learn sign
language?‟
Conflicting advice around:
A more directed or self-reflective
method of developing parent-child
interaction skill;
speaking when the child is unable
to see the speaker or using as
many visual cues as possible to
support communication;
Conflicting advice around:
(contd.)
whispering or using an
appropriate level of volume;
accepting or not accepting nonverbal attempts to communicate;
modelling and recasting or
expecting repetition.
Key Questions
What does research tell us about
those strategies which are most
effective in the promotion of language
and communication development for
deaf children?
How can we ensure that the advice
offered by the team around the child
is co-ordinated and consistent?
Key Questions, contd.
How can we ensure that families
feel empowered rather than
confused by the different
agencies?
Advice to parents regarding
the use of the home language
(and factors influencing this
decision)
and the variation in practice
dependent upon the
cultural background of the
family
NDCS
Professional support “should
recognise the cultural and linguistic
needs” of the child and the family;
Cochlear Implant Centres should be
expected to provide “a family liaison
professional or a community worker”;
provide (them) with a spoken
language interpreter and/or a sign
language interpreter”;
NDCS, contd.
“information should be available
which is appropriate…ideally it should
be in (the parents‟) first language”;
parents “can request that the cochlear
implant team provide (them) with a
spoken language interpreter and/or a
sign language interpreter”;
NDCS, contd.
“the team (should) recognise the
importance in many families of
maintaining their first language”.
Respondents‟ Feedback
Need to:
be flexible and innovative;
ensure that all families receive the
same information and equitable
support;
develop a partnership between
parents and professionals;
Respondents‟ Feedback, contd.
engage in multidisciplinary
working;
use the home language, adhering
to one language where possible
in initial stages;
adhere to „person specific
languages‟;
Respondents‟ Feedback, contd.
Key factor is to build up effective
communication in the family using
the language they prefer and then
discuss how English, and BSL if
relevant, might be introduced.
Challenges encountered
Having access to a wide range of
interpreters for the variety of
languages;
ensuring that the interpreters interpret
exactly what has been said;
trying to assess the child‟s level of
ability in their home language
accurately;
Challenges encountered, contd.
children‟s ability to access tonal
languages, such as Mandarin;
families finding it difficult to
access the level of language used
by professionals as well as written
information;
Challenges encountered, contd.
child‟s needs, including the
consistent wearing of their
devices, not seen as a priority
within the family, or the wearing of
devices not considered culturally
‘acceptable’.
„Fridge‟/developmental cards
Parents encouraged to
personalise them and tailor them
to their family „traditions and
heritage‟
„Fridge‟ card example
Card B3 has three suggested activities:
Choose toys that build on your child‟s
interest…;
Continue to develop your child‟s
awareness of turn taking through
frolic play;
Use rhyme and songs linked to
rhythmic movements.
Points Raised
Potential for communication
breakdown if money not available for
interpreters or if interpreting expertise
not readily available;
difficulties arise when child is trying to
communicate with other family
members if only one language, i.e.
English, becomes focus;
Points Raised, contd.
child directed speech from main
parent/carer not the model by which
children learn their language;
lack of culturally appropriate materials
for assessment and advice makes a
differential diagnosis difficult if
language is not developing as it
should;
Points Raised, contd.
development of use of eye contact
and visual attention for young deaf
children and for Deaf families
important but not so acceptable or
appropriate for some cultures;
important that practitioners
themselves are able to communicate
with the parents in their first
language, e.g. BSL.
Key Questions
How do we ensure that we all give
the families coherent and culturally
sensitive advice and advise about
strategies, bearing in mind cultural
differences in early language
stimulation, for example, the use of
eye contact, play, nursery rhymes
and child-centred communication?
Key Questions, contd.
How can we ensure that the families
from other cultures feel comfortable
acting upon the advice given?
How do we develop the expertise in
assessing language development in
the home language and therefore be
able to make accurate differential
diagnoses if language is not
developing in the way it should?
Key Questions, contd.
Is there any evidence for working
via the siblings of a young deaf
child, rather than the adults, to
develop the deaf child‟s language
skills?
What is the evidence base for
children with cochlear implants
accessing tonal languages?
Key Questions, contd.
How can we ensure that
practitioners are trained to a level
whereby they are able to
communicate with families,
preferably in their first language,
e.g. BSL?
In Conclusion
Presentation has:
outlined and explored a series of
issues experienced by some
professionals (further endorsed
by data collected from an open
questionnaire);
raised a series of questions
In Conclusion, contd.
Symposium intended to
give further voice to issues, so
that we may begin to consider
how some of the questions raised
can be addressed in the light of
current research in order to
support future evidence based
practice.
Thank you for listening