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Cochlear Implant Education Center

What is a CI?
Decision Making
Language and Communication
Deaf Community
Speech Processor
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Training the Ear to Listen

Developed by Debra Berlin Nussbaum, Coordinator, Cochlear Implant Education Center, Laurent Clerc National Deaf Education Center

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The process of learning to make sense of sound will differ for each child depending on his or her age, prior experiences with listening, language competence, and other characteristics (see Factors Influencing Performance Outcomes). To optimize listening, speech, and spoken language outcomes, it is recommended that children receive some type of auditory and speech habilitation services following implantation either through their hospital implant center, their school program, or a private practice. Development of spoken language skills may effectively be addressed in individualized therapeutic sessions, integrated into the child’s natural environments (home or classroom), or a combination of both. Some children may learn best in a therapy setting, whereas others may readily develop skills in more natural settings.

Recommendations regarding the frequency of habilitation services should be specific to each child. Immediately after implantation, the child may require more frequent and focused attention on skill development. As spoken language foundations are established, the frequency of individualized training should be revisited. A habilitation program should continue as long as the child is progressing in his or her development of spoken language skills.

Auditory habilitation services should be provided by knowledgeable professionals with cross-disciplinary skills in three primary areas: audiology, speech-language pathology, and education of children who are deaf. The professionals should have training and experience with the development of auditory, speech, and language skills for children with hearing loss.  Increasing numbers of training/certification programs are preparing professionals to facilitate spoken language for children with cochlear implants. However, experienced specialists who do not have formal certification may be qualified to provide the necessary services. It is important to explore the qualifications of the professional who will be providing services to each child to assure that he or she has the necessary training and experience.

For more information about the recommended qualifications for habilitation/rehabilitation specialists, see Roles of Speech-Language Pathologists and Teachers of Children Who are Deaf and Hard of Hearing in the Development of Communicative and Linguistic Competence.  Developed by a Joint Committee of ASHA and the Council on Education of the Deaf , this publication provides useful guidelines for speech-language pathologists.

Equipment Troubleshooting
A child’s success with an implant depends on the device’s consistent functioning. Although it is not common, the internal component of the implant device can fail. More common are issues related to the malfunction of the implant’s external speech processor; especially the child’s individualized program settings. As the brain adjusts to sound, what may have at first been comfortable and "loud enough" to the child may become insufficient and "not enough." A child’s changing responses to sound may occur quickly and become clearly apparent or happen slowly and go unnoticed, similar to a light on a dimmer that grows dim so slowly as to almost be imperceptible until it becomes too dark. A child may also inadvertently have electrodes set for too much stimulation during a mapping session, causing discomfort. If this occurs and is not remedied, the child could possibly begin to experience listening as negative and may resist using the cochlear implant. If a child is functioning with an inappropriate map, this will negatively impact progress with the implant.

To assure optimal functioning, it is critical that professionals working with the child are comfortable with the device, know the personal device settings for each child, and check the device on a daily basis. School professionals needing support with this process should request guidance from an educational audiologist in their school system and/or an audiologist from the hospital implant center.

Equipment Check
There are two types of checks on a cochlear implant that can be completed daily both at home and in school—an equipment check and a check of the child’s functional listening.

Information about how to troubleshoot implant devices can be found on each manufacturer’s website.

Include the following in an equipment check:

  • Use signal check devices (available from the implant manufacturers-see below) to check the integrity of the transmitted signal when connected.
  • Check all batteries daily (a weak battery will make a difference).
  • Check coils and cables for wear and tear.

Cochlear Corporation

Wand to verify that the speech processor’s transmitting coil is sending a signal across the skin to the implant.

transmitting coil 

Monitor earphones to check whether a processor’s microphone and internal amplifier are receiving sound. Monitor Earphones only detect a signal from the microphone or an attached accessory. They don’t assess signal quality or represent the processed sound a recipient hears.
monitor earphones 

MED-EL: Speech Processor Test Device

MED EL speech processor test device


Advanced Bionics Signal Check Device

Advanced Bionics signal check device

Functional Listening Check
In addition to a physical check of the equipment, it is equally important to check a child’s performance with the equipment on a daily basis. One such check, familiar to many, is the Ling Six Sound Test. This check involves presenting a series of specific speech sounds at a consistent loudness and distance from a child to document his or her sound awareness. When a child demonstrates a change in sound awareness from an established baseline response, this may reflect a possible change in a child’s listening potential that may require attention to his or her map or an equipment malfunction.

This quick and easy check involves the following steps:

  • Have the child sit at a distance of about three feet wearing his or her implant.
  • Cover your mouth with a listening hoop (a specially designed barrier to present sound without distortion). This hoop can be made using an embroidery hoop with two layers of acoustic speaker cloth. If you do not have a listening hoop, cover your mouth with a barrier that does not distort the sound.
  • Individually present each of the following six sounds: “mm,” “oo,” “ah,” “ee,” “sh,” and “s.” (These sounds represent the variety of the frequencies present in speech.)
  • Have the child respond to sound (e.g., raise a hand, place a block into a container) when it is audible.

Note about the Ling Six Sound Test for children with cochlear implants: Present each sound at a quiet level. You want to confirm that the child is consistently aware of “very quiet” sounds. If you present the sounds too loud, it is difficult to determine when it may be time to return to the hospital implant center to adjust the setting of the speech processor.

For more support with the Ling Six Sound Test:

The Stages of Listening and Speaking Development
Children with cochlear implants are typically able to detect very quiet sounds throughout the frequency range integral to understanding spoken language. Detection of sound, however, does not automatically guarantee that an individual will develop the skills to comprehend spoken language for learning (see Factors Influencing Performance Outcomes). There are many pre-requisite skills a child must develop before he or she will be able to understand and use spoken language. The following progression details a typical hierarchy a child may follow in learning to understand and communicate through spoken language. How far and how quickly a child progresses is individual to the characteristics of each child.

Receptive listening skill development and Expressive skill development chart

For more information about listening, speech, and spoken language development:

A.G. Bell Association: Listening and Spoken Language Knowledge Center

Equal Voices for Deaf Children

Garber, A., &Nevins, M. E. (2010, December). HOPE Bulletin—Auditory Skill Development

Garber, A., & Nevins, M. E. (2010, December). HOPE Bulletin—Spoken Language Development

Assessment of Listening, Speech, and Spoken Language
There is a variety of formal and informal tools available to assist in gathering information about a child’s spoken language functioning to guide in planning habilitation goals and strategies. These tools can be used to document listening, speech, and spoken language before and after implantation.

Checklists and questionnaires:

      For more information on assessment tools:

      Garber, A., & Nevins, M. E. (2010, December). HOPE Bulletin—Assessment Measures

      Assessment tools from Advanced Bionics (annotated list of listening, speech, and spoken language assessment tools)—Test Reference for Cochlear Implants

      Auditory, Speech, and Spoken Language Guides
      There are published guides available to provide a framework for the development of listening, speech, and spoken language skills. While various guides may propose a full program to follow, it is not necessary to fully use any one guide. There may be helpful hints and activities to gather from various guides. Skill development need not follow a cookbook approach. Determining effective strategies will be individual to each child. For skills to be beneficial in the child’s life, these skills must be integrated and supported within the child’s natural environment.

      Auditory, Speech, and Spoken Language Practice Activities
      Listening practice materials are available through the cochlear implant manufacturers and through other sources. Some are available for purchase and others are directly accessible online at no charge. Some provide interactive activities and games. Others provide materials to download to facilitate activities.

      Cochlear Corporation:

      Advanced Bionics:


      Other Sources:

      Starfall—A free website to teach children to read with phonics. For preschool, kindergarten, and first grade. Phonics games and online interactive books.

      Equal Voice for Deaf Children (EVDC)—Resource designed for families who do not have access to a qualified therapist to help their child acquire spoken communication skills

      Listening Tree—A subscription that allows access to hundreds of printable listening and language activities. Listening tree has a Spanish version with Spanish weekly activities

      Storyline Online—Stories read aloud by members of the Screen Actors Guild (with captioning)

      AOLkids—On-line stories read aloud

      Superduper Publications—iPad apps for auditory and speech habilitation

      ESL Lab: Website with mini lessons for learning English as a second language

      ABCya.com provides a wealth of free educational kids computer games and activities for elementary students to learn on the web.

      Integrating Sound for Learning
      While a child may be able to listen effectively within a controlled therapy environment, it is important for individuals communicating with the child to be aware of how to best present spoken information to him or her so he or she will successfully be able to understand what is being said in the natural environment. For children who are new to listening, or only have beginning-level listening skills, they may not be able to understand complex, fast-paced communication. It is important for individuals who communicate with the child, to understand the child’s current level of auditory functioning and incorporate strategies to guide the child in deriving meaning from sound.

      Learning how to adjust communication variables in the natural environment is central to the concept of auditory habilitation/rehabilitation. The listening difficulty of a communication experience can be adjusted so a child can have success in listening at his or her level. The listening experience can also be adjusted to provide increasing challenges to the listening situation so the child can improve his or her listening.

      When the following factors related to the content and/or presentation of information are controlled during either a structured listening activity or in the natural environment, any listening situation can be designed to be either readily accessible or challenging.

      These content-related factors can be modified:

      • the familiarity of vocabulary,
      • the number of items in a choice set (e.g., three choices, four choices, open set),
      • the acoustic contrast of items in a choice set (e.g., shoe versus elephant), and
      • the number of critical elements (e.g., big red shoe, ball under the bed).

      These presentation-related factors can be modified:

      • the rate of presentation,
      • the acoustic highlighting (e.g., emphasis on key words),
      • the visibility of a carrier phrase (e.g., a phrase leading up to a key word or words), and
      • the number of repetitions.

      Another beneficial strategy to assist children in deriving meaning from sound is the “sandwich” technique. The sandwich technique involves linking information sequentially via auditory and visual modes.

      Two examples of the sandwich technique are as follows:

      • Auditory-Visual-Auditory: Say it-sign it-say it or Say it-say it adding speechreading-say it
      • Visual-Auditory-Visual: Sign it-say it-sign it-say it adding speechreading-say it -say it using speechreading

      Professional Training: Auditory Habilitation
      To guide professionals in learning about auditory habilitation for children with cochlear implants, there are numerous on-line professional training tools offered through the cochlear implant manufacturers including:

      Cochlear Corporation: HOPE Courses (archived on a variety of topics specific to auditory habilitation: http://hope.cochlearamericas.com/online-courses

      Advanced Bionics:

      The AG Bell Academy for Listening and Spoken Language offers certification for listening and spoken language specialists (LSLS) as either auditory-verbal therapists (LSLS Cert. AVT) or auditory-verbal educators (LSLS Cert. AVEd). The Professional Preparation in Cochlear Implants (PPCI) represents a multi-center collaboration to address both the medical and educational aspects of pediatric cochlear implantation. PPCI is specifically designed for teachers of deaf children, speech-language pathologists, and educational audiologists to provide training and experience in providing (re)habilitation services to children with implants.


      Revised June 2014