“But They Turn Their Head When I Call Their Name!” The Role of SLP in Pediatric Cochlear Implant Candidacy Evaluation and Family Counseling

Published in the March 2024 issue of the ISHA Voice.

By Caitlin Gomez and Michelle Havlik

Caitlin and Michelle are members of the Medical Practice Issue Committee.

20 month-old Ainsley twirls around at the sound of a tambourine across the therapy room. She laughs and playfully grabs the instrument from the clinician and performs her own rambunctious solo. “See! She turned right away when you shook the tambourine! I just don’t understand how her hearing can be that bad!” Shortly after, the clinician sits to the side of Ainsley, out of her direct line of sight. She presents a variety of sounds in conjunction with a variety of toys. A long “ssss” for a snake crawling towards Ainsley, a “hop hop hop” for a wind-up bunny. Ainsley plays quietly to herself for the most part, but occasionally turns to the clinician and acknowledges certain sounds with a grin. “See, she can hear those sounds, she’s just stubborn when she plays and doesn’t always like to include others.” 

Children with hearing loss are at-risk for speech and spoken language delays. Those with bilateral, severe-to-profound sensorineural hearing loss, like Ainsley, have limited auditory access to their family’s native spoken language. Given that 90% of children with hearing loss are born to hearing parents, some degree of listening and spoken language (LSL) development is often a goal of the family (Mitchell & Karchmer, 2004). For families who have LSL as a goal, immediate and ongoing audiological management is paramount to a child’s progress. The Early Hearing Detection and Intervention (EHDI) guidelines (at both the state and federal levels) promote a “1-3-6” model of identification and intervention for children with hearing loss (White,2022). In this model, the goal is for a child to be screened for hearing loss by 1 month of age, receive a full audiological evaluation by 3 months, and fit with hearing technology and placed in appropriate early intervention services by 6 months. During this “1-3-6” journey, the family is faced with an abundance of new terminology and new professionals to remember–all while processing the diagnosis of their child’s hearing loss. Caregivers are thrust into a new world of terminology surrounding communication choices for their child. They entrust professionals to provide unbiased information regarding these choices. Among these communication choices are learning a signed language (such as American Sign Language (ASL)), cued speech, and listening and spoken language. In the case of Ainsley, whose parents have chosen LSL as a goal, audiological management is paramount. 

In-depth audiological assessment allows a child to receive hearing aids programmed specifically to his or her hearing levels, offering optimal amplification to frequencies critical for speech detection and understanding. However, hearing aids often provide limited auditory benefit to children with severe-to-profound hearing loss. For the family with the goal of optimizing their child’s listening skills, cochlear implantation may be considered. The American Cochlear Implant Alliance (ACIA) Taskforce Guidelines for pediatric cochlear implant candidacy list the following clinical criteria as reason for referral for cochlear implant candidacy evaluation: audiometric thresholds greater or equal to 70 dBHL, less than 50% accuracy on aided word recognition testing, and poor functional auditory performance marked by limited progress with traditional amplification (Warner-Czyz, 2022). 

“I’m interested in learning about cochlear implantation, because we have a goal for Ainsley to listen and talk. But I’m not sure if a cochlear implant is needed, as her word recognition scores went all the way up to 50% when she had her hearing aids on in the sound booth during testing!”  expressed her mother to the speech-language pathologist (SLP).  

Cochlear implant candidacy evaluations often take an interdisciplinary approach which includes assessment and collaboration between audiologists, otologists/otolaryngologists, speech-language pathologists (SLP), social workers, nurses, and many others. The speech-language pathologist conducts a variety of assessments to evaluate a child’s communication skills including: listening, receptive/expressive language, articulation, and social language skills. An SLP who specializes in working with children with hearing loss provides crucial information on a child’s baseline communication skills, how those skills compare to their same-aged hearing peers, how the child’s decreased hearing levels adversely affect his or her listening and spoken language development, and how they are performing in comparison to their hearing age. Hearing age is the number of months or years since the child was fit with hearing technology and therefore has had access to sound. For example, although a child’s chronological age may be 4 years old, if they received their hearing aids at 3 years old, their hearing age is 1 year old. Comparison of a child’s hearing age with their LSL scores and their aided speech perception helps the clinician counsel parents on if and how the child’s current hearing aids are helping them meet their fullest LSL potential. This information helps the parent understand why a cochlear implant is being recommended by a hearing loss center even though their child is “hearing better” than they were prior to hearing aid fitting. The information from the assessment gives the family a picture of their child’s hearing loss from a functional lens, rather than just a percentage score. The variety of objective and subjective assessment tools highlighted below are used to capture a child’s communicative strengths as well as identify gaps in their skills. 

“It’s our goal for Ainsley to go to kindergarten with her neighborhood friends. Is she communicating at the same level as her same-aged friends? It seems like her friends at the park talk a lot more while they play, some of them are even putting two words together! Ainsley typically just screams or laughs while she plays.” 

Standardized assessments are a critical piece of the diagnostic process. Conducting standardized assessments enables the clinician to identify a child’s skill levels and provides standardized scores which are compared to the assessment’s normative sample of age-matched peers. Although standardized assessment is only one piece of an SLP’s evaluation, these results provide caregivers with an objective look at how their child’s skills compare to his/her same-aged hearing peers. Moreover, eligibility for support services in the public schools often relies heavily on standardized scores to determine eligibility. Finally, standard scores on speech and language assessments allow for the clinician to conduct progress monitoring re-evaluations each year to document the rate of skill development is commensurate with their hearing age or hearing history. 

“It seems like Ainsley hears us more than what the audiology testing revealed. She follows our daily routine at home no problem! At our local library toddler group, she’s able to follow along in the group activities without help, but it seems like she waits and watches what her friends do before participating. How do I know how her hearing loss is affecting her?”

Criterion-referenced listening checklists and questionnaires are another important piece to the diagnostic process. Unlike standardized assessments which compare a child’s performance to a normative sample of same-aged peers, criterion-referenced assessments evaluate a child’s mastery of specific concepts and behaviors. There are many auditory skills checklists and questionnaires which evaluate a child’s listening development within the context of real-world listening scenarios. For example, the LittleEars questionnaire by MED-EL starts off with basic environmental sound detection questions such as “Does your child take interest in toys that make music or sound?” and advances to questions regarding auditory comprehension of more complex commands such as “Take off our shoes and come here.” Performance on criterion-referenced assessments aid in development of individualized long- and short-term goals for therapy, as they identify the skills in which the child has yet to master. They identify rate of progress in comparison to hearing age and help gauge whether their current devices or programs are optimized for continued LSL development.  In addition to caregiver-reported questionnaires, there are also instruments geared towards exploring a child’s listening skills within a classroom setting. Listening skills are essential to effective participation in the classroom and overall academic growth. Tools such as the Listening Inventory for Education - Revised (LIFE-R) asks the child’s classroom teacher about specific listening scenarios at school and whether the child experiences difficulty. This tool gives the clinician a better impression of the child’s functional listening skills in their classroom listening environment. 

In addition to standardized assessments and functional listening checklists and questionnaires, the SLP completes additional assessments of the child’s overall communication skills. These assessments may include, but are not limited to: oral mechanism examination, language sampling, oral narrative sampling, phonological awareness/literacy assessment, and pragmatic language assessment. 

“The audiologist has recommended a cochlear implant evaluation after they completed her aided testing in the sound booth. Is this necessary if we want Ainsley to listen and talk? What did your testing show?” 

The SLP dedicates a significant amount of time to counseling and education during a cochlear implant candidacy evaluation. The clinician synthesizes the results of each assessment and examines whether the child’s error patterns are common for children with this type of hearing profile. The SLP trained in working with children with hearing loss has the task of determining whether identified skill deficits are due to limitations in the child’s auditory access. When a child has auditory skills on par with their hearing age and yet they present with delays in speech and language skills not matching their hearing age, additional etiologies for their delays should be considered. For example, the clinician would not expect a child with a hearing age of 2 years to present with speech and language skills commensurate with their chronological age of 3 years, as a child will initially present with speech/language skills reflecting their years of experience with hearing. In the case of Ainsley, she presents with limited auditory benefit from her hearing aids and her speech and language is reflective of what we would expect with her limited functional audition. Therefore, she would likely be considered a candidate for cochlear implantation.  However, if she had displayed excellent auditory benefit from her current hearing aids, but continued to present with significant delays in speech and language this would warrant consideration of additional etiologies contributing to these delays. An analysis of her error patterns would help determine if her delays are a result of limited audition versus presenting with other communication disorders such as a phonological delay, autism spectrum disorder, or apraxia of speech. 

There are factors which should be considered while counseling a family considering cochlear implantation for their child. First, many parents are navigating their child’s hearing loss diagnosis with minimal prior background knowledge or experience. Some caregivers may experience a grieving process which includes emotional states such as denial, guilt, depression, anger, and/or anxiety (Luterman, 2006). It is the responsibility of the clinician to respond empathetically towards parents as they process their child’s recent diagnosis. It is also the responsibility of the clinician to determine whether additional referrals to professionals such as psychiatrists, social workers, and hearing loss support groups are warranted. A child’s LSL outcomes are contingent upon his/her parents being supported, informed, and active participants in the therapeutic process. 

Second, the SLP should be familiar with the different adult learning styles and tailor their counseling to each family as such. Caregivers of children with hearing loss come to the table with their own educational experiences and learning styles. This affects how the family best receives, absorbs, and applies information. For example, one parent may be a visual learner, in which graphs and visuals such as the Familiar Sounds Audiogram, may be a helpful tool. Another parent may be an auditory learner, in which recording counseling sessions so the family can review information after the visit may be beneficial. As the SLP establishes rapport with the family, taking note of each member’s learning style promotes effective caregiver/clinician interaction and ultimately optimizes LSL outcomes. 

“I didn’t realize that Ainsley’s hearing loss could be affecting her communication in so many different ways! This conversation has really helped me understand how her hearing tests translate to real life situations.” 

Here, Ainsley’s mother now presents with a clearer understanding of how her daughter’s functional listening skills are impacting her potential for meeting listening and spoken language skills commensurate with her peers. Pairing this information with empathetic counseling and education in a manner which matches their adult learning style will help best setup the child with hearing loss and their family for success.

The decision on whether or not to pursue cochlear implantation after a child is determined a candidate belongs to the family. In addition to how the child’s hearing loss adversely affects his/her spoken language development, caregivers should also consider a variety of factors such as family support system and cultural values. It is the responsibility of the clinician to provide the family with knowledge and resources that allow them to make informed decisions regarding their child’s plan of care. The clinician provides this information to the family with additional emphasis on the importance of capitalizing on the critical period for language learning during the first five years of life. Some parents express the desire to let their child choose cochlear implantation for themselves when they become older. However, research supports “earlier is better” with cochlear implantation and subsequent listening and spoken language outcomes (Ching, et al, 2018). The clinician informs the parent of this research. Ultimately the clinician respects the decision of the family if they wait until the child is older to make the decision for themselves. However, it is also their responsibility to counsel the family on realistic expectations of the child’s listening and spoken language outcomes, as duration of deafness is a contributing factor to a child’s LSL trajectory. 

The SLP communicates their diagnostic findings and the family’s communication goals with the interdisciplinary team. This information is documented using a cochlear implant candidacy tool such as the Child Cochlear Implant Profile (CHIP). The rest of the team then uses this information in their own visits with the family to reinforce key counseling topics such as the importance of consistent device use, adherence to the follow-up schedule, and fostering a language-rich environment at home and at school. 

The SLP’s assessment toolbox is vast. Using a combination of standardized assessments and functional listening questionnaires enables the SLP to provide crucial information during a child’s cochlear implant candidacy evaluation in a sensitive and evidence-based manner reflective of the family’s chosen communication approach.  Parents of children like Ainsley are then empowered to make an informed decision on whether to proceed with cochlear implantation or not. The rapport, trust, and open communication style the clinician has established, over likely multiple visits, results in an effective counseling and education experience for the parent, and ultimately fosters a supportive environment for the child’s future development.

References:

Anderson,K., & Smaldino, J. (1998) The Listening Inventory for Education: An Efficacy Tool (LIFE). 

Audiogram of Familiar Sounds: What Does My Child Hear? . John Tracy Center . (2019). https://www.jtc.org/audiogram-of-familiar-sounds/ 

Cole, E. B., & Flexer, C. A. (2007). Children with hearing loss: Developing listening and talking. Plural Pub. 

Ching TYC, Dillon H, Leigh G, Cupples L. Learning from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study: summary of 5-year findings and implications. Int J Audiol. 2018 May;57(sup2):S105-S111. doi: 10.1080/14992027.2017.1385865. Epub 2017 Oct 12. PMID: 29020839; PMCID: PMC5897193.

Hellman, S. A., Chute, P. M., Kretschmer, R. E., Nevins, M. E., Parisier, S. C., & Thurston, L. C. (1991). The development of a children's implant profile. American Annals of the Deaf, 136(2), 77-81.

Kuhn-Inacker, H., Weichbold, V., Tsiakpini, L., Coninx, S., & D’Haese,P. (2003) Little ears: Auditory Questionnaire. Innsbruck, Austria; MED-EL. 

Luterman, D. (Ed.). (2006). Children with hearing loss: A Family Guide. Sedona, AZ: Auricle Ink. 

Mitchell RE, Karchmer MA. Chasing the mythical ten percent: Parental hearing status of deaf and hard of hearing students in the United States. (PDF) Sign Language Studies. 2004;4(2):138-163.

Warner-Czyz AD, Roland JT Jr, Thomas D, Uhler K, Zombek L. American Cochlear Implant Alliance Task Force Guidelines for Determining Cochlear Implant Candidacy in Children. Ear Hear. 2022 Mar/Apr;43(2):268-282. doi: 10.1097/AUD.0000000000001087. PMID: 35213891; PMCID: PMC8862774.

White, K. (2022). A Resource Guide for Early Hearing Detection and Intervention. Infanthearing.org. https://www.infanthearing.org/ehdi-ebook/2022_ebook/1b%20Chapter1EvolutionEHDI2022.pdf  

Caitlin Gomez, M.S., CCC-SLP is a licensed American Speech Language Hearing Association (ASHA) certified speech-language pathologist who specializes in working with children with hearing loss. She has worked at UChicago Medicine and has been a member of the Pediatric Cochlear Implant and Hearing Loss Program since 2019. Her interests include providing comprehensive speech and language interventions in both spoken language and American Sign Language (ASL). She is currently working towards obtaining her credential as a Listening and Spoken Language Specialist Certified Auditory Verbal Therapist (LSLS Cert. AVT). Caitlin obtained her Master of Science degree in Speech Language Pathology from Western Illinois University in 2014, and her Bachelor of Science degree in Communication Sciences and Disorders from Western Illinois in 2012. 

Michelle Havlik, MHS, CCC-SLP, LSLS Cert. AVT is a licensed American Speech Language Hearing Association (ASHA) certified speech-language pathologist who specializes in listening and spoken language development in children and adult patients with hearing loss. She has worked at UChicago Medicine and has been a member of the Pediatric Cochlear Implant and Hearing loss Program since 2009. She became a Listening and Spoken Language Specialist Certified Auditory Verbal Therapist (LSLS Cert. AVT) in 2014 and was a credentialed Early Intervention specialist and evaluator from 2007-2022. She obtained her Master of Health Science degree in Communication Disorders from Governors State University in 2006 and her Bachelor of Arts degree in Speech-Language Pathology from Elmhurst College in 2001. In addition to her work at UChicago Medicine, she’s presented at professional conferences, served as a consultant in research studies and as an adjunct professor for St. Xavier University’s Communication Sciences and Disorders Department from 2017-2019.