Candidates for cochlear implants frequently ask about the need or the role of speech rehabilitation.

Cynthia Robinson, the founder of We Hear Here (wehearhere.org) has more than four decades of experience in the field as an educator teaching deaf and hard of hearing children to listen and talk.

A Phi Beta Kappa graduate from the University of Richmond, she received her master’s degree in Deaf Education from the Curry School of Education at the University of Virginia. She was a faculty member and for several years, the Co-Director of the Clarke Schools for Hearing and Speech in Jacksonville Florida.
With her experience as a Listening and Spoken Language Specialist, she is an advocate for mainstreaming children with a hearing loss. She is the author and co-author of several books on the subject as well as the designer of classroom programs to facilitate this objective.

I had the opportunity to ask her to explain why early intervention is important for pediatric cochlear implant candidates and how delay can influence the success of the outcome.

She also offers insights on success of prelingually versus later deafened adults who receive a cochlear implant.

Cynthia elaborates on the role of speech therapy and offers suggestions for finding local sources for speech and language specialists.

Transcript

Richard:
Cochlear implant Basics is a site for candidates and their families and friends. If you have been told you qualify for a cochlear implant, these podcast interviews tell how receiving a cochlear implant can be a life changing experience. You will meet Mississippians who face a hearing loss and that hearing aids could no longer provide comprehension of speech or music. They face growing isolation, inability to socialize or compete in the world of business. The joy of music disappeared. They explain how receiving a cochlear implant changed their lives. Welcome to Cochlear Implant Basics. A reminder, Cochlear Implant Basics is not sponsored by anyone nor is it offering medical advice. Please consult your own healthcare provider.

Richard:
Good morning. I’m talking to Cynthia Robinson and today’s topic is about speech therapy because I know many people have questions about it. So we’ll start with Cynthia, would just give me your name, date, and where you are.

Cynthia Robinson:
My name is Cynthia Robinson. The date is Friday, August 13th, and I am in a very hot St. Augustine, Florida.

Richard:
Okay it’s hot in Sarasota too. They say people move to Florida for the air conditioner.

Cynthia Robinson:
That’s right.

Richard:
I need to basically ask a little bit about your background and then I’ll go into specific questions.

Cynthia Robinson:
Okay.

Richard:
Your background is an educator for speech therapists. Tell me a little bit about what that role is.

Cynthia Robinson:
My background is in education for the deaf and hard of hearing, and I’ve been doing it for a very, very long time. Beyond 45 years. I came into the field before cochlear implant technology. So I was trained to work with children that could not get full access to sound. Some children benefited from hearing aids and some not so much. So I’ve had two halves to my career. The first half was very remedial and trying to work with children tactically, visually, to produce spoken language. And then the second half of my career was after pediatric implants that I was able to work with people that had access because of the miracle of technology for cochlear implants.

Richard:
Well, how do you test if somebody is a candidate for speech therapy? Is there a method you use pre cochlear implants and today?

Cynthia Robinson:
So I think the most important thing, and I will speak primarily from my perspective as an educator of young children, even though I’ve had some limited experience with adults, who’ve gotten cochlear implants, is that what happens when we get cochlear implants is that it’s not acoustic hearing, it’s not natural hearing. It is a substitute for natural hearing. And typically once the implants are activated, people will report hearing beeps and clicks initially, then that progresses to sort of robotics speech patterns. And then finally the brain makes a complete adjustment into recognizing speech naturally. And it sounds very natural to the person’s ears and sounds very natural when they speak with other people.

Cynthia Robinson:
So in order to get from beeps and clicks to that wonderful, oh wow. I’m hearing everything very similarly to the way other people hear it. It requires training the brain. And so by working with someone who’s trained to do this process to help the brain acclimate to the signal, you facilitate the progress to really understanding, listening and spoken language. And depending on the individual and where they were at the time they got implanted, that process may be relatively short or it may be longer.

Richard:
Well, we know that people who get cochlear implants have to rehabilitate to get very, very successful results. We understand that. But I was intrigued sometimes when I hear people who’ve gotten cochlear implants that were pretty lingually deaf, they never really seemed to get to pure speech. Your ideas about that?

Cynthia Robinson:
Yeah. There’s actually a very good reason for that. If a child is born, prelingually deaf and that child is identified and the child gets technology with cochlear implants within the first 12 to 18 months, because there is FDA approval starting at, I think it’s 10 months now. So if you get that implant at three, wow, okay.

Richard:
I don’t know if it’s FDA approved but I know surgeons.

Cynthia Robinson:
Okay I don’t know any surgeons who’ve done that. I know a few who’ve done nine months, but I don’t think three’s [inaudible 00:05:31]. Anyway, if the children get implanted early, we’re looking at the auditory cortex. So we’re getting the signal from the implant in the cochlea to the auditory nerve and up to the auditory cortex. If you look at the auditory cortex before implantation, you will see nerves running through that auditory cortex, but you will not see nerve bundles. So once the child is implanted, those nerve bundles start to form and what those nerve bundles are, is connections. The brain is connecting and building a robust system that helps us understand and use spoken language and produce it as well, of course, is a big part of it. That is neuroplasticity. It is primarily active between birth and three, it starts to drop off between ages three and five, and by age seven, that neuroplasticity has substantially deteriorated.

Cynthia Robinson:
You sort of look at it like a can of Play-Doh. In the beginning, it’s very, very pliable. If you leave it out for a while, it becomes stiff. But if you work it hard enough, it’s reusable. But if you leave it out over night, when you come back in the morning, it’s too hard to do anything with. And I think that’s a really good way to understand neuroplasticity.

Cynthia Robinson:
So if you’re looking at an adult who has never heard spoken language and decides to get a cochlear implant, probably, there are always exceptions to every rule, but probably you are never going to help that individual really access true spoken language. They will get detection, they will know that there is sound or not sound, they may get discrimination, which is, oh, I hear a couple of things and they’re different. They may even get identification for some things like I hear a siren, I hear a jackhammer, but they may never get to that point of full comprehension of spoken language because the auditory cortex has already given up on forming those connections for sound. And it has moved on because every piece of our brain is valuable. The auditory cortex has moved on to process visual stimulation and tactile stimulation.

Richard:
This all makes a lot of sense. And I just have to use my own example because I lost most of my hearing while I started having a progressive hearing loss from scarlet fever when I was five. And I wore hearing aids from the age of seven, and I did go to speech therapy for several years. My mom dragged me everywhere, which was fine. I also would to address the fact or the story because I do have two pediatric mothers who have interviews with me. And again, when parents find out their children have a hearing loss, there’s total panic. What do I do? They deal with the internal conflict. Do I give them a cochlear implant now or let them decide in the future? And I’d like you to address that situation.

Cynthia Robinson:
Well, what I tell the parents of young children, number one as a professional, I always have to honor the fact that it’s a family’s choice, what to do. It is not my choice as a professional to make that decision for them. It’s my responsibility as a professional, to provide them with information so that they can make the decision that they feel is right for their child and their family. If a family’s goal is for their child to have listening and spoken language, you cannot wait because the neuroplasticity will disappear. So you have to make a decision for that child. You cannot wait for the child to be old enough to make the decision for themselves, or you’ve missed the opportunity.

Cynthia Robinson:
I do work with families who want their children to be bilingual, both in spoken language, French, English, whatever, or bilingual in terms of knowing sign language and spoken English. And what I tell them, if they want to be bilingual for sign language and spoken language, whatever language that is, is that they must address the spoken language first. That the ability to learn sign language, and this is just scientific, the ability to learn, sign language, the brain’s ability to do that does not disappear. That option will always be there for them. But if you don’t get the implant, when the child is very young, you will lose the possibility to develop listening and spoken language because the Play-Doh will have gotten hard.

Richard:
That makes a lot of sense. And I know, I have mentored parents that struggled with that question. And because I mentor people in 24 times zones, I have to be very much aware of different cultural aspects of having a cochlear implant. Sometimes it’s a little difficult to get them over that hump to say, yes, your child’s going to have a cochlear implant that’ll stick out. But if they’re deaf, it’ll be worse. I would like to address adults. You’ve worked with adults who have gotten cochlear implants and now need speech therapy. How do you determine they need that therapy?

Cynthia Robinson:
Any adult who gets a cochlear implant in my professional opinion will need some therapy because they’re learning to use that implant. So we start at the sound level and we work up to the word level, and then we work into sentences and phrases. And by then, they’ve acclimated and they can understand. Pretty much everybody will need that. If a person has gotten their implant pretty soon after having lost their access to hearing, it’s going to be a faster process for them. The longer the person has been away from having hearing, the longer it may take their brain to adjust. But if those nerve bundles are there in the auditory cortex, they will adjust. It’s just going to take them time. But if it’s the prelingually deaf adult, who has never heard spoken language, yes, they will still benefit from therapy because working at the sound level, they will learn that detection, discrimination, identification. And they may even get to the place that they can recognize some words, but it’s going to be a much longer process for them.

Richard:
You’ve just given me food for thought here. Is there a way for the surgeon to see if those nerves have formed before he does surgery?

Cynthia Robinson:
I don’t know whether there’s a way for surgeons specifically to look at that, but it’s just a brain scan. It’s non-invasive and it’s used for research. And that’s how we had that information, is that researchers go in, look and see what is the situation for people who are deaf? What does the auditory cortex look like? And like I say, it’s non-invasive and then they look at deaf children. Well what does it look like? And then they look post-implant and they look at hearing people. So that’s how we have this information about the nerve bundles.

Richard:
Is that scan commonly done? Frankly, I’ve never heard of it before. And I would imagine that somebody who is a candidate, who’s worried, is this going to work? What will I get if I got a CI, if they had some information beforehand about their possibility, the chances of success would give them confidence to move forward.

Cynthia Robinson:
As far as I know, it’s not common in clinical practice, it’s more used in a research setting.

Richard:
That’s fine. I understand. Now, one of the other things I know that cochlear implant recipients who live alone, rehabilitation is tricky. I mean, I’ve created my own rehabilitation programs, which I share with people to do it on their own. Is any sort of remote rehabilitation available to cochlear implant candidates?

Cynthia Robinson:
I don’t know about the adult population. Even before COVID, I was involved in a lot of telepractice with families of young children. And of course, once COVID came, everything moved to telepractice. So I would suspect that if an adult reached out to a clinic that specialized in working with adult implant users, they would find that telepractice is available, but really COVID has started kind of a new trend. There was a lot of hesitancy about the efficacy of telepractice before COVID, but then there wasn’t any choice. And so now I guess, good news, bad news. One of the things that we’ve been able to gather during this time period is how much efficacy is there to doing clinical practice through telepractice alone. And it’s actually turned out to be that it’s quite successful. So I would say that reaching out to a center that you would reach out to in person, but you don’t live close to them, or you don’t want to travel there, or you’re self isolating because of things that are going on in the community is that reach out to them and just say, I’d like to do this through telepractice.

Richard:
I would hope at the end, you can give us a list of sources that people could go to.

Cynthia Robinson:
What I can suggest, and I don’t really have a list of sources, but what I can tell you is if a person goes to the Alexander Graham Bell website, they can look up people who are certified as listening and spoken language specialist, and they can search for listening and spoken language specialist by state. And it will tell you whether that person’s background is speech therapy or education, but everyone listed on the Alexander Graham Bell Academy website is a listening and spoken language specialist. So you can find them there.

Richard:
That’s a terrific piece of information. Would you like to add anything to the people that we’re talking to about speech therapy and cochlear implants?

Cynthia Robinson:
I think as far as families go, the sooner they have this done, the better off the child is. And I think in terms of adults, having realistic expectations based on what your hearing history is, because we don’t want people to go through surgery and be very disappointed. So I think helping a person examine their hearing history and the probability that the implant will work for them, in the way that they want, is very important because everyone determines success differently. Some adult user might say I’d just be satisfied if I can hear a big noise around me, if I can just monitor my environment a little bit. Whereas another person might say, I’m not going to be satisfied. Success for me is if it sounds just like I remember the voice sounding or if I can appreciate music. So I think looking at each individual’s goals along with their hearing history for an adult is probably the most important thing to consider.

Richard:
That’s fantastic information. I’m sure people are going to benefit tremendously from this interview. So I thank you so much for your time.

Cynthia Robinson:
You’re so welcome. I’m very honored to be asked.