Clinicians, teachers, and parents are gearing up for the upcoming season: No, I don't mean spring, but IEP Season! That's the period of time that can drag out from now until virtually the last working day on a school district's calendar. In an earlier blog entry, " IEP Listening Goals for Children with Cochlear Implants - Part 1", I offered four goals that were starting points for many children who have received cochlear implants. I see these as essential for any child who is beginning to develop auditory abilities....however, these goals may still be appropriate for the experienced child with a CI. Certainly, the first goal, that of responding to the Ling Sounds as a way of verifying device integrity, is universal and I generally recommend it continue through grade school, at minimum. Actually, listening verification checks such as the Ling Sounds may take on more, rather than less importance as a child ages, because the child may start using multiple pieces of listening equipment. Each of those equipment pieces bring both the potential for enhanced listening, but also for breakdowns, such as lack of coupling of multiple devices (FM with the cochlear implant), interference with the FM signal, or the ever-common dead batteries. Many children are receiving second cochlear implants, as well. With most of these students, we have to go back to square one in doing individual-ear listening checks with the new and old (first) CI. It is NOT adequate to do a listening check on a bilaterally-implanted child in only the bilateral condition. In the early months and even years of binaural listening, children do not have the ability to sort out which device may be malfunctioning. If the two devices are not checked independently, a child potentially could be listening with one of the implants under-functioning or not working at all. I recommend that the Ling sound checks continue to be listed on the IEP, and that they be conducted at the beginning of the school day and the beginning of any pull-out or individualized session of tutoring or therapy. With a child's increasing age and listening experience, the clinician should try to make listening checks more challenging by presenting Ling Sound from a greater distance, using a softer voice, adding some voiceless repeated consonants such as "p-p-p" or "k-k-k", and/or adding some real words to the stimuli. Remember to always record the condition in which they were presented, such as "From 15 feet, soft voice." One of the reasons to continue doing Ling Sound checks at the beginning of speech-language sessions is to remind the SLP, who often is not highly experienced working with children wearing CIs, how important the auditory environment is for these children, and how listening conditions affect performance in this population to a much greater extent than they do with typical- hearing children.

As a new semester of school approaches, it is a good time for clinicians and parents to review a child's IEP; to get a mid-year reading on the child's progress toward his or her stated goals. Yet, as experienced educators know, it is not just the child's progress we assess, but our own development as clinicians. Many of us have on our caseloads children with cochlear implants, but are unsure of the modifications we should be making to progressively challenge a student's listening development. Using principles from a chapter I published recently in Cochlear Implants – Principles and Practices (2009; John Niparko, Editor), I offer some practical tips for clinicians: 1) Integrate perception and production goals. Therapy activities should contain both a listening and speaking component whenever possible, allowing the clinician to cover considerably more training in each session; 2) Develop a "dialogue' rather than "tutorial" therapy style. Rather than the clinician serving as the dominant conversational partner (as in a tutorial format), the dialogue format emphasizes turn-taking and switching of roles by child and clinician. The demands placed on the child differ when the child is the listener vs. the speaker; 3) Utilize communication sabotage. First described by Lucas-Arwood in the child language literature, communication sabotage is used to teach the child that s/he must be prepared for the unexpected and that listening is unpredictable; 4) Use drills consistently but judiciously, following a "quick, fun, get-it-done" approach. Drills are important for rapid motor practice of speech targets and for achieving many repetitions of a target in a short period of time. But, just as hitting against a backboard is good practice for tennis strokes but unsatisfying in and of itself, so drills are a critical component of intelligible speech work but should not be confused with real-world communication. As a last word, I am glad to be blogging again, following a period of technology breakdowns that took considerable time to resolve. The main theme I extracted from that experience? Back up, back up, back up! Happy Near Year.

Some IEPs written for children with cochlear implants (CIs) do not reflect the individual and unique listening needs of these students. After all, the CI is and AUDITORY aid, designed to stimulate the AUDITORY cortex and thus, to allow for AUDITORY skill development. It is logical for us to begin our discussion of IEP goals by reviewing some of the basic auditory behaviors that would be appropriate to include on the IEP. Readers will recall, of course, that every child is unique and goals must be written that are individualized and appropriate. But, I would like to suggest 4 auditory goals that are starting points for almost any child with a CI (we'll call our student Luke.) 1) The Ling 6-Sound test should be administered with each ear individually at the beginning of the school day. This ensures that Luke's devices are functioning properly. The Ling Sounds should be repeated throughout the day after recess, anytime Luke has had his device removed or turned off, and at the beginning of speech or tutoring sessions. 2) A goal should be set for Luke to gradually increase his awareness of when his devices are working, and to report when they are not. This skill develops over time, with reinforcement from adults, but the first step is for Luke to tell us, "I hear it" or "I can't hear" when queried by the teacher. Later, we expect a child to tell us spontaneously when the battery is dead or the device is otherwise malfunctioning. 3) The teacher should be able to get Luke's attention in class by calling his name, without any other cues. Teachers sometimes tap a child with a CI or wave their hands in front of the child's face, while also calling their name. Under this condition, it is impossible to tell if the child is responding through listening or via the other cues presented. Thus, teachers need to practice securing a child's attention by calling his name and expecting the child to respond. If the child does not respond, the teacher should approach him and say, "Luke, I was calling your name. I said, Luke. Did you hear me? That's your name: Luke." This approach conveys to the child that, although he may not be able to demonstrate this behavior at the moment, the teacher has set an expectation for it, is optimistic about the child's ability, and will support his mastering this skill. 4) Luke should begin to attach meaning to auditory signals in the classroom. Some examples of these would be the school bell; knocking on the door; music that signals a certain activity (e.g., the teacher begins to sing, "Days of the Week" song as a cue for the children to gather around for calendar time; or, as I observed in a classroom recently, a teacher who clapped her hands with a specific rhythm to secure her Kindergarteners' attention during learning center time. When they heard the clapping, the children would quiet and repeat the clapping sequence, moving on to their next learning center. Cochlear implants convey these cues accurately, so Luke and other children with CIs are learning to recognize and attach meaning to these signals and routines. But these skills don't develop automatically – they need to be the focus of instruction and be monitored regularly so that we can increase the challenge level of auditory goals once Luke achieves them.

Good things are happening all over the place! The Wrights Law conference on IEP's that I attended recently was terrific. I always feel satisfied when I've taken a day away from my practice to attend a continuing education event and it turns out to be really productive, as this one was. I also did a school consultation today with one of my patients who has bilateral cochlear implants whom I've followed since age 17 months. He received his first implant at age 21 months and the second at age 4 1/2. He is fully mainstreamed in a general education Kindergarten and his school district has contracted with me to provide some inservice to the staff.How gratifying it was to see his classroom teacher, so devoted to all 26 of her students, yet attentive to my patient's needs, wearing the FM transmitter to increase the audibility of her voice, and clarifing things for him when needed. He has a team that provides special pull-out services 5 days a week - 3 times by an SLP, and 2 times by a teacher of HH/D. Everyone at the school wants to learn more about bilateral cochlear implants and to direct their energies toward using strategies that will help him master his IEP goals most efficiently.I left his school realizing that, although I may be discouraged by the special education situation of some of my students, there are also many excellent programs and dedicated school staff who work wonders every day. It's important that I remember these success stories and celebrate them - even though I'll continue to push for more appropriate services and IEPS for other students.

It's back to school time and already several of my families have called with concerns about something that has happened at school with their child who wears a cochlear implant. The calls all have one thing in common: the child's IEP is not being followed by school personnel. In one case, the school district had agreed to hire an outside expert to consult with the regular education staff regarding how to accommodate a 6-year old child with a cochlear implant. He has age-appropriate language skills when tested, but still is at a distinct disadvantage in the classroom and the staff need information about how to check his devices to make sure they are working, how to position him for maximum audibility, and so on. The IEP states that the consultation will occur BEFORE the start of school, so the staff could be prepared prior to his first day. Two weeks into the school year now and no one has contacted the consultant. The parents don't know if they should be tough with the school or continue to gently prod, as they already have about 3 times. In another situation, a student with autism and deafness/cochlear implants is not getting the services clearly outlined on her IEP, including consultation from the district's Autism consultant to her classroom teacher. She's also getting lists of spelling words that are not in compliance with the IEP goals – her lists were supposed to be shorted and the words chosen were meant to be those appropriate for her language level. I guess no where in the area of special-needs children do I see this "Tragic Gap" more often than in the IEP – is it just a stack of papers where the letter but not the spirit of the law is followed? Teachers are maxed out with pressures on them, school districts have restricted budgets, and with these factors I empathize. But at the end of the day, as it says on the "Wrights Law" website, it is the school's, not the parent's responsibility to provide the funding and scheduling of what has been written in the IEP. I'll be taking a full-day IEP course from the Wright's Law folks in September, and will write my next few blogs on this important topic.

The growing number of children who are receiving a second cochlear implant has prompted all of us to scramble in looking for appropriate intervention techniques. There was a time when lots of clinicians thought it made sense to take off the first cochlear implant for a time, hypothesizing that the second or "new ear" needed a chance to learn to listen. Children often protested this recommendation, attesting to the fact that they were highly dependent upon the signal from the first device and did not like to be without it.

At the recent Pediatric Cochlear Implant 2009 International conference in Seattle, some fascinating presentations were given by experts in bilateral cochlear implantation. One of the key take-away points was that, in order to develop the bilateral auditory neural pathways that support two-eared listening, children need lots of experience exploring sound with BOTH cochlear implants on. While some limited time with only the newer implant is often appropriate in the first weeks after second implant activation, children benefit more from listening with two ears, just as you and I do every day. In the next few blogs, I want to explore binaural cochlear implant rehabilitation and provide some practical suggestions.

I also want to say how proud and humbled Chris Barton and I were to learn that Tune-Ups, our integrated speech/music curriculum, had been voted MVP – Most Valuable Product of 2009 in the Speech-Language category, by readers of Therapytimes.com. Thank you to all who voted for this product for those who are discovering ways to use it creatively with their patients! Please share your ideas with us. To learn more about TuneUps, go to www.hearingjourney.com.

I'm preparing to leave for the International Cochlear Implant symposium in Seattle, being held this week from Thursday to Saturday. We'll be hearing on many state-of-the-art topics, and the beneficial effects of early cochlear implantation will be front and center. Profoundly deaf babies, identified at birth through universal newborn hearing screening, are receiving cochlear implants as early as six months of age. The listening and spoken language skills of these children are so impressive clinically. The results of physiological measures confirm that early exposure to sound also allows neurological maturation of the auditory cortex - so these babies brains are directly affected by input from the implant. Parents of babies identified as deaf deserve to learn about these data when they are making decision for their children. I'll be speaking at the meeting on the topic of "Music and Spoken Language in Pediatric Cochlear Implant Rehab: A therapeutic Alliance." There are a number of interesting papers on the program on the topic of music appreciation and performance in children with cochlear implants. Oh, by the way, if you haven't voted yet, I hope you'll consider a vote for "Most Valuable Product" (MVP) for the integrated music and speech therapy program called "TuneUps" written by Chris Barton and me. You can check it out at www.hearingjourney.com and go to the Listening Room at that site. We hope you find it to be a useful clinical tool, no matter what population of children you serve. Vote for your favorite clinical products and share the information with others!

The ways in which I incorporate music into my speech-language practice have been on my mind alot recently. First, becuase "TuneUps," the integrated Music and Speech Curriculum writen by Chris Barton, my music therapy colleague and me, has been nominated for an MVP (Most Valuable Product) award by TherapyTimes readers. Chris and I are truly honored and excited. Mostly, we hope this indicates that even more in the field are making use of music and its power as part of all kinds of interventions, even those who aren't Board certified Music Therapists. "TuneUps" is published by Advanced Bionics and can be ordered at www.bionicear.com. Several children with cochlear implants or hearing aids sing back-up! Chris composed virtually all the songs on the CD, and together we wrote a guide to help clinicians utilize the songs as springboards to other ideas, including personalizing them for a child's special interests. I worked yesterday with a 2-year old patient with bilateral cochlear implants. Although born deaf,with the cochlear implants he is now talking up a storm and gravitates towards all kinds of music. I used one of the songs from "TuneUps" called "Hoppity Hop" to expand the depth of his vocabulary, particularly with verbs. He'd pick a toy animal, we'd sing the song and I'd introduce and act out new verbs, such as "Leap, leap, Leap-i-ty Leap" or "Yawn, yawn, yawn-i-ty Yawn." This was pure fun for him, yet the language learning was so evident. I hope you'll check out "TuneUps" and even cast a vote for the MVP award, if you like what you experience. In any case, keep on making music.

In a therapy session this morning, I was reminded of the balance between novelty and routine that exists when working with babies who are HH/D (hard of hearing and deaf). Young children with cochlear implants and with hearing loss in general, often have a gap between their cognitive and linguistic abilities and this influences our choice of therapy materials and the way we conduct intervention. I spent the hour-long session pulling out familiar toys at 26-month old Paul's repeated requests: "Want ducks!" - then watching him lose interest after a short period of time. During those moments, I had an arsenal of never-before-presented toys that I would present, using communication temptation to elicit more verbal attempts from Paul. The session had this back-and-forth rhythm, reminding me that part of the art within the science of early intervention is knowing how to balance a baby's competing interests in routine, (infants enjoy playing with the same objects repeatedly) and novelty (extending the child's attention by introducing new toys on a regular basis.) Keep working on your comfort level with the balancing act, fellow clinicians.

I had the privilege of presenting at the ASHA Health Care Conference in Washington, DC this past weekend, and talked about managing young children with cochlear implants. One of the great resources I shared was the "Learn to Talk Around the Clock" parent-baby curriculum by Karen Rossi. This curriculum is based upon a number of signature behaviors for parents to use that are reinforced throughout the program, and which contribute to the development of listening and spoken language. Parent-friendly lessons are divided into practical categories relevant to young children such as Mealtime, Celebrations, Outdoor Play, and so on. Within each category there are 8 levels corresponding to the increasing age and ability of the child. I make a photocopy of the lesson and talk to the parent during our session, then send the lesson home for the family to utilize throughout the week. Karen provides a list of toys and books that will reinforce the concepts for EVERY lesson! Recently, she published, "Learn to Talk Around the Clock at Childcare," the only curriculum I know designed specifically for those providing childcare to children with hearing loss. The lessons are easy to use and give practical suggestions for busy childcare staff - with helpful "Awareness Bracelets" for staff to wear to remind them to utilize a specific technique with the CI child. A simple but enormously effective technique. Check these out at: www.learntotalkaroundtheclock.com