This document will provide you with the following information on the Cochlear Implant Program at the Central Speech and Hearing Clinic (CSHC) in Winnipeg, Manitoba:

• Pediatric criteria for cochlear implantation
• The Pre-Implant Assessment Process
• Parental Responsibility
• The Surgical Procedure
• The Post-Implant Process

PEDIATRIC CRITERIA FOR COCHLEAR IMPLANTATION

1. Severe-to-profound hearing loss for most frequencies in both ears.
2. The hearing loss may be:
   a. congenital (present at birth),
   b. prelingual (acquired before the age of two) or
   c. post-lingual (acquired after the development of speech and language).
3. Receive little or no benefit from hearing aids (usually determined through a trial period of consistently using two hearing aids) as indicated by whether age-appropriate communication skills are developing.
4. The family participates in the auditory-verbal therapy program and the child is placed in a preschool/educational setting that relies on spoken language (an oral approach) to ensure the best possible outcomes from the implant.
5. The family is willing and able to take part in extensive pre-implant evaluations and post implant follow-up services.
6. The child’s parents/guardians, and whenever possible, the child understand the range of possible benefits and limitations of the cochlear implant and the risks involved.

No medical conditions that would prevent the cochlear implant surgery.
“WE’RE NOT TRAINING THE EARS. WE ARE TRAINING THE BRAIN TO INTERPRET WHAT THE EARS HEAR.”
Doreen Pollack, Audito-Verbal Pioneer 

THE PRE-IMPLANT ASSESSMENT PROCESS

Throughout the pre-implant process, the team will determine if the child meets the criteria for implantation. In order to do so, a number of appointments with the following team members are needed:

Cochlear Implant Audiologist
The Cochlear Implant Audiologist will need to see your child several times in order to assess his or her hearing with and without hearing aids. A number of tests will be needed, including:

• Ear-specific pure tone air and bone conduction testing
• Electroacoustic analysis of hearing aids to ensure appropriate fitting
• Aided soundfield testing, including speech perception testing

Auditory-Verbal Therapist or Speech-Language Pathologist

The Therapists use a family-centred approach to help deaf and hard of hearing children learn to develop spoken language skills by training them to listen with their devices (hearing aids or cochlear implants). During the pre-implant process, you and your child will attend regular auditory-verbal therapy sessions in order to receive ongoing evaluation of your child’s speech, language, and auditory skill development. Formal assessments in these areas are also done. The therapist helps parents to carry over the techniques and strategies which promote listening and spoken language skills to everyday routines and activities. During the post-implant process, families continue to attend for regular auditory-verbal therapy sessions. More information on AV therapy can be found at: www.agbell.org

Parent Coach

The Parent Coach will meet with the family throughout the candidacy assessment. Speaking from personal and professional experience, the Parent Coach helps guide parents by discussing issues such as expectations, rehabilitation needs and family support.

Surgeon

The Ear-Nose and Throat (ENT) surgeon will meet with you to explain the surgical procedure and to answer any and all questions you may have prior to surgery.

Other Medical Consultants

The ENT will refer your child for a CT scan and an MRI. A vaccination against pneumococcal meningitis will also be done at your family doctor’s office. Other medical examinations may be done at the request of your family doctor or ENT.

Cochlear Implant Team

The Cochlear Implant Team consists of the individuals listed above. During the pre-implant process they will all teach you how an implant works, why therapy is crucial to successful outcomes and support you in your decision to teach your child to listen, hear, and speak. Once the evaluations, assessments, and hearing aid trial has been completed, a team meeting takes place. This is referred to as a ChIP meeting (Children’s Implant Profile). The whole child is considered and the team screens for any potential issues that might affect the child’s ability to learn language with an implant. Often other professionals may be involved in the care of your child. If this is the case, these professionals may be invited to the ChIP in order to provide information necessary to determine your child’s candidacy. Following the ChIP you will have the opportunity to address any concerns regarding your child’s candidacy.

Peers and Families
During the pre-implant assessment process, it is recommended that parents meet with other families and their children who have been through the cochlear implant process. The Staff at the Central Speech and Hearing clinic assist in providing opportunities for families to meet, share experiences, and learn from one another. Parents are also encouraged to gain as much information they can on cochlear implants and language development. Information kits are available from our audiologists and parents are encouraged to make use of the Parent Library at the Central Speech and Hearing Clinic.

PARENTAL RESPONSIBILITY

Parents often ask about their responsibilities. They include:

• Understanding the importance of following through with daily practice of the therapy goals.
• Commitment to attending all appointments, both pre- and post-surgery.
• Preparing your child for hospital procedures.
• Ensuring consistent and effective use of the hearing aids/implant equipment.
• Providing effective feedback on your child’s development.
• Monitoring, caring, and maintaining the equipment and surgical site on a daily basis.
• Commitment to attending the auditory verbal therapy program. Children require intensive long-term (re)habilitation to help them develop their language, listening skills, speech production and communication behaviours.

THE SURGICAL PROCEDURE

The following are some common questions parents have about the surgery:

How long is the surgery?
The surgery takes about 3 – 4 hours and your child usually remains in the hospital until the next day. The recovery time is fairly quick and many children feel back to normal the next day. Most children return to school within one week.

What are the risks involved?
When you meet with the ENT surgeon in Winnipeg he will explain the risks involved and will answer any questions you may have about the surgery.

When will my child start to hear?
It usually takes 2 -3 weeks for the incision to heal. The cochlear implant(s) will be activated at least 4 weeks after surgery to allow for the incision to be fully healed.

Where does the surgery happen?
Although the pre-implant assessment and post-implant programming is done at the Central Speech & Hearing Clinic in Winnipeg, Manitoba, presently the surgery is being done at various centres outside the province. Your child will be referred to one of several surgical centres following the candidacy process.

Is this covered by Manitoba Health?
Manitoba Health will cover all medical expenses incurred for the purposes of the surgery, as well as reimburse you for your travel costs (air fare for your child and one adult). The internal and external cochlear implant devices are also covered by Manitoba Heatlh.

You will be required to stay in the city where your child’s surgery is done for up to four days post-surgery to be seen by the surgeon for a post-op follow-up appointment. Accommodations, food, and ground transportation in the city are not covered by Manitoba Health; however, CHSC staff can provide you with information regarding reduced rate hotels and other assistance, if needed.

Is there any financial support offered to families?
Families who participate in auditory verbal therapy have the opportunity to have costs associated with equipment, travel, therapy needs, reimbursed through a generous donation from the Elks and Royal Purple Auditory Verbal Fund.

What is the cost of maintaining the cochlear implant(s)?
For the first three years after the cochlear implants are initially programmed, the implant company provides a free warranty. After the three years, parents are provided the opportunity to purchase service agreements (extended warranties).

THE POST – IMPLANT PROCESS

Every child is different, so your audiologist will need to work with your child over several appointments in order to find the right settings for your child’s cochlear implant. The programming is done by connecting your child’s speech processor (the external device that looks like a hearing aid) to the computer and creating a ‘map’ for their cochlear implant.

Initial programming of the speech processor will take place four to six weeks following surgery. This will require 2 consecutive days with the audiologist(s). The speech processor will be programmed frequently thereafter.

Post-implant assessments will occur regularly after initial programming of the device. With your written permission, this information will be shared with your child’s school to assist teachers and other professionals in providing your child with best possible educational program.

Ongoing auditory-verbal therapy is essential to ensure that a child with a cochlear implant receives maximum benefit from the device. Research outcomes show that children who are in strong auditory/oral environments that promote listening and spoken language allow for children to benefit the most from cochlear implants. It is recommended that every child receives auditory-verbal therapy for a minimum period of two years post implant. 

It cannot be predicted how well any child will progress with a cochlear implant. A child's progress will depend on many factors:

1. The age at which the child became deaf.
2. The length of time the child has been deaf.
3. The home and educational setting.
4. The level of family involvement and support.
5. Prior use of hearing aids
6. Family and child’s motivation
7. Child’s level of speech and language development.
8. Primary mode of communication.
9. Child’s cognitive development and learning style.
10. Presence of cochlear abnormality 

Research indicates that children who have the best results are implanted at the earliest possible age. Of importance for parents considering cochlear implantation is the critical period for speech and language development, which is 0-5 years of age. Currently, the minimum age for implantation in Canada is 12 months.

 Parents should be aware that the cochlear implant:

1. will not provide normal hearing.
2. will not guarantee intelligible speech.
3. will not guarantee educational success. 

However, with consistent use of the cochlear implant(s), enriched spoken language environments and ongoing auditory-verbal therapy, the sound your child hears through the implant(s) will become meaningful and will enhance your child's ability to listen, hear, and speak.

** Thank you to the Cochlear Implant team from the Hospital For Sick Children in Toronto, Ontario who allowed us to use their document as a model and template for the development of this document.