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Star can’t hear cheering crowd tarchdeacon@coxohio.com 10/30/2011 2:35 AM

ARCANUM — In the last home game of his extraordinary high school football career, Arcanum senior Dustin Shiverdecker will do everything — except for one thing — that a guy could do tonight.

He’ll play halfback against visiting Covington. On defense, he’ll line up at outside linebacker. If the Trojans need him to switch to cornerback, he’ll do that, too. He’ll handle the kicking chores. And the punting.

He’s one of Arcanum’s most versatile players and one of the big reasons the team has turned around its season. After opening 0-3, it has won five of its last six games.

And tonight, when the Trojans marching band takes the field at halftime, he very well could be out there with it performing “Sweet Caroline,” the White Stripes’ “Seven Nation Army” and Taio Cruz’s “Dynamite.” He’s a member of the band’s percussion section, and the only time he doesn’t join it is when he’s playing football.

The guy everyone calls Shivy is one of the most popular students in the small Darke County school. Besides football, he’s a standout wrestler, a sprinter on the track team and one of the top long jumpers in the Cross County Conference. He’s also a budding cook and something of an artist and, as football coach Jason Stephan put it, “He’s one of those guys you enjoy being around, both as a coach and a teacher. He’s just a terrific kid.”

That’s why folks will be cheering tonight when he escorts his parents, Ryan and Angel, onto the field for Senior Night festivities. Unfortunately, though, he won’t be able to hear that heartfelt salute.

He’s been totally deaf since birth.

Although at age 5 he was fitted with a cochlear implant — a surgically affixed electronic device that his dad said gives him up to 85 percent hearing of a sort in one ear — he doesn’t wear it during football games.

“We tried it freshman year but the moisture under his helmet made it shut down,” said his mom. “We tried cleaning it and changing batteries, but it just kept going out.”

So now Dustin plays football by relying on reading lips, hand signals — a sort of gerrymandered sign language the players and coaches came up with — and moving when he sees the snap of the football.

The system is working. As a running back, he has 386 yards on 77 carries this season. As a defender he has 59½ tackles in nine games. He ran for a decisive touchdown in a victory over Bethel last week. In the come-from-behind 15-12 upset of Ansonia this year, he scored all the Trojans’ second-half points, kicking a 23-yard field goal and then wrestling a 16-yard touchdown reception away from a defender in the end zone.

When he makes a big play at home games, Dustin instinctively looks up to the top corner of the bleachers and finds his mom, who stands there reflecting the roar of the crowd in her smile and then quickly relays an “atta-boy” with some sign language of her own.

“I can’t hear the cheers,” Dustin said, “but I always look for my mom and her reaction lets me know, and I feel good.”

A big decision

When Dustin was a baby, his parents sensed something wasn’t quite right because he didn’t always respond like he should. Angel said by the time he was 3, they were told he just needed tubes in his ears.

“We got them, but two weeks later we took him in for a check-up and right off they said, ‘Your son is deaf.’ At first we were devastated. It was like, ‘Where do we go? What do we do?’ We didn’t know anybody and Ryan and I were so young as parents, but we just tried to grasp all the information we could.”

As he thought about those times, Ryan just shook his head.

“We went to Children’s (Medical Center). We went to Cincinnati and met the deaf community there. And then we heard about cochlear implants and met with some people who had them.”

In the process they stepped into an often heated debate — manualism vs. oralism — that goes back some 300 years in the deaf community. One group believes deaf students are better educated through sign language. The other believes in education through spoken language.

“We took Dustin to a school for the deaf in Cincinnati and they wanted to keep him there during the week and then we could come get him and be weekend parents,” said Angel, who is a child support investigator for Darke County. “We fought that. We said, ‘No, he’s part of our family and we’ll parent him at home.’ We’re a hearing family and we wanted him to be part of that, not separated from us.

“We did a lot of soul searching on what to do. The deaf community pretty much hates cochlear implants. To them it’s like turning your back on that culture, but we decided to go that direction because Dustin’s life here, the community here, is all hearing and we wanted him to be a big part of it.”

According to the National Institute of Deafness and Other Communication Disorders, there were some 28,400 children in the United States using cochlear implants as of last December. Although the sound that’s provided isn’t as rich as natural hearing — and can be difficult to decipher in noisy settings — it works, as 5-year-old Dustin found out in jarring fashion when doctors first fitted him with the device and turned it on.

“You’ve got to remember he’d never heard anything until then, so when they turned it on there were suddenly all these different sounds and he cried and pulled at the thing to get it off,” Ryan said. “But then everything became a new experience. He heard a bird and it was like, ‘What the heck was that?’ ”

From kindergarten through his sophomore year in high school, Dustin was accompanied by a woman who was his classroom interpreter. The past two years, though, he has gone without her because Ryan and Angel and most of the Arcanum teachers thought Dustin could handle school on his own and they felt sometimes an interpreter was a crutch he could fall back on.

While Ryan went to football practices when Dustin first joined varsity to help with communication problems — and Angel still accompanies him to various school conferences, the most recent a meeting with the Jostens representative who was explaining class rings — the couple has stressed that their son tackle things on his own.

Sports has helped, and over the years Dustin has taken part in almost everything Arcanum has to offer. Along the way, though, there have been a couple of rules.

“No quitting anything halfway,” Ryan said. “You start something, you finish it.”

Stephan said the couple also instructed the coaches not to treat their son any differently than they would anybody else: “They said yell at him the same as you would anybody else. Demand the same. Don’t expect any less.

“Sure, there have been times when it’s been frustrating for Dustin and for us because of a communication barrier here or there, but we’ve always gotten through it.”

‘The right attitude’

Had you been at football practice the other day, you would have seen two of the Trojans assistant coaches — Doug Morris and Jason Hart — giving Dustin face-to-face instruction before many of the plays.

In the classroom, the learning has sometimes gone in the opposite direction as well, said band director Doug Albright:

“Dustin is one of those kids where it’s a growth experience for you to have him in your group. I hear people coming into the classroom grumbling about this or that, but I’ve never seen him that way even one time. I’ve just never seen him act like he’s having a bad day. He has the right attitude.”

And that’s what Stephan said he’ll remember most: “A lot of kids could learn from him. I think of how many might have an ailment or a disability or have been told they can’t do something, so they just accept that. Dustin never has. He just works hard and perseveres.

“After this I know he’ll be successful in life because of the way he’s tackled the challenges here. I really think he could play at a small college somewhere, especially if he just concentrated on one position. Here, in a small school like this, when you have a kid with that kind of athletic ability and aggressiveness you’re forced to play him as much as you can.”

Should the Trojans topple unbeaten Covington tonight they will make the playoffs. But regardless, this will be the last game for Dustin on the Arcanum field.

“Friday night I’ll be sad,” Angel said. “He has done so many things out there — just like in the rest of his life — that have amazed me. It’ll be rough to see it end. I’m sure I’ll be in tears.”

Ryan, who works on the chain crew during games, shook his head: “I’m not really sad. I’m just ready for the next thing in life for him. He impressed me as a child and all through high school, so I want to see what he’s going to do next. He just keeps impressing people.”

No one put that more succinctly than Morris, the Trojans’ defensive coordinator:

“I think a lot of folks here are like me. I don’t look at Dustin as a deaf kid. He’s just a kid. ... One heck of a kid, really.”

GREAT EXPECTATIONS: PERSPECTIVES ON COCHLEAR IMPLANTATION OF DEAF CHILDREN IN NORWA

AMERICAN ANNALS OF THE DEAF - VOLUME 154, NO. 3, 2009

GREAT EXPECTATIONS: PERSPECTIVES ON COCHLEAR
IMPLANTATION OF DEAF CHILDREN IN NORWAY

The authors describe the use of cochlear implants with deaf children in Norway and examine how this intervention has raised new expectations and some tensions concerning the future of education for
deaf students. They report on two studies of communication within school learning environments of young children with implants in Norwegian preschools and primary/elementary schools. These studies involved observations of classroom discourse and teaching activity and interviews with teachers, administrators, parents, and pupils. Results suggested varied patterns of use of Norwegian and of Norwegian Sign Language and several modes of communication, including speech alone, sign alone, and speech with sign. Conclusions are drawn regarding the reasons for the observed variations and the future impact of cochlear implantation on educational policies and services for deaf children and their families in Norway.

People were overwhelmed with amazement. “He has done everything well,” they said. “He even makes the deaf hear and the mute speak.” MARK 7:37 (cited in Norwegian Directorate for Health and Social Affairs
[2006], p. 1)

The use of cochlear implants with young deaf children has accelerated over recent years to a point where many of these children are fitted with single or bilateral implants in their first year of life (Hyde & Power 2006). This process has been considerably aided by the widespread implementation in most developed nations of programs of universal newborn hearing screening, or UNHS (Yoshinaga-Itano, 2003).

These programs have the capacity to identify the nature and degree of hearing loss in the first few weeks after birth (Morton & Nance, 2006). Audiological and neurological processes follow diagnosis to ascertain the best possible candidates for implantation, with surgery taking place for many children with severe or profound hearing loss sometime in the first year after diagnosis. Many major benefits of earlier diagnosis and implantation have been reported (Fitzpatrick, DurieuxSmith, Eriks-Brophy, Olds, & Gaines, 2007; Yoshinaga-Itano, 2003; Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998), but other outcomes have also resulted that require major changes in how deafness in young children is accommodated by policies and service systems, including those for education (Thoutenhoofd, 2006; Young & Tattersall, 2007).
Of note is the need for families to deal with the diagnosis of their child’s hearing loss at an earlier age, when there has typically been no previous suspicion of hearing loss. The important process of relationship building
between parents and infant may be disturbed by the real or imagined consequences of a hearing loss for their
child, for them, or for their aspirations for their child. As Young and Tattersall (2007) have suggested, early identification is of little value if it is not combined with services designed to assist families in utilizing the potential time advantage that has been gained.
Much of the information that parents acquire about deafness and implantation, and about conditions for a
deaf child’s development, is received directly from health or education professionals associated with the referral process after newborn hearing screening has occurred. Parents are placed in a situation in which they are required to make early decisions about implantation and how to conduct their interactions with their child to form relationships and develop learning to enhance the child’s opportunities for communication, socialization, and cognitive development.
As well as the contexts of individual families, there are the broader political, social, cultural, and educational contexts in which decisions are made and services are provided. Decisions about the child’s development and future are made in dynamic personal, familial, and emotional contexts that are embedded in the political and policy traditions in health, social development, and education that a nation provides for its citizens. In this way, the processes of early identification of hearing loss and cochlear implantation, as well as the nature of the responses of health and education systems, may be seen as part of an inclusive approach.
Most nations aim to support access by citizens to equitable opportunities for development and learning through participation in society. In education in particular, national governments provide policies and practices that are directed toward inclusive outcomes  for all children. As Hyde (2009) has noted, these policies and practices are not global, but are grounded in societal values and tempered by a nation’s political, cultural, social, and historical traditions and resources. Expectations can therefore vary considerably regarding cochlear implantation of deaf children. In some countries, the desired outcome may well be a form of equitable participation in daily life, development, and learning processes in academic and social settings. In other countries, the demand for excellence may also be a driving influence. “Excellence” may be defined in these contexts as leading toward “oral perfection,” while “equitable participation” may be less esteemed. Where both are present, tensions can simultaneously become evident among parents and professionals, and within policy and service systems. The Norwegian education system has “equity in education” as a national goal and overriding principle. Equity in education implies that positive discrimination is required, and leads to the claim that inclusive education means that the system must adapt to each individual and group. Adapted education as an educational principle, in turn, focuses on the individual needs of each child. In line with current national policy, however, establishing satisfactory bilingual educational settings for individual deaf children within inclusive educational settings in local schools remains a considerable challenge (Hyde, Ohna & Hjulstad, 2006). Classroom studies of learning environments for children
in so-called inclusive settings in Norway have revealed that students are often exposed to some exclusive
communication practices (Ohna et al., 2003). Ohna and colleagues found that gaining access to a common communication and learning environment was dependent on the classroom structures and the pedagogical practices used by teachers, and in some cases by interpreters. Consequently, patterns of interaction were created that could either create constraints on communication or enhance the use of the classroom languages, and subsequent learning. In the present article, we consider the situation of cochlear implantation of deaf children in Norway in its specific educational and policy contexts.


The Incidence of Permanent Hearing Loss and the Use of Cochlear Implants in Children in Norway
Norway is a country of about 4.7 million people, with its population spread across a large geographical area. In Norway, approximately 0.1% of newborn children have some form of hearing loss, and since 2008 all hospitals have participated in newborn hearing screening (Helse og omsorgsdepartementet [Ministry of health and care services], 2007). The incidence of permanent hearing loss is similar to rates observed in other developed countries (see, e.g., Mehl & Thomson, 2002), that is, typically 1 per 1,000 with a permanent bilateral hearing loss of 40 dB or greater. Of this population, at least 30% may be predicted to have a severe sensorineural hearing loss and 10% a profound loss ( Johnston, 2004; Yoshinaga-Itano, Coulter & Thomson, 2000), accompanied in some cases by detected or undetected retrocochlear complications. The profoundly deaf group comprises the most likely candidates for cochlear implantation.
It is anticipated that the recent full implementation of UNHS in Norway will significantly lower the age of diagnosis of hearing loss and increase the potential for earlier fitting of hearing aids or implants and the commencement of forms of parent/family support at earlier stages. In other countries that have implemented UNHS, age of confirmed diagnosis has been reduced from an average of 24–30 months to 2–3 months (Morton & Nance, 2006; Young & Tattersall, 2007). With the implementation of UNHS in Norway there is already evidence of an earlier detection process unfolding, with 4 children under 12 months of age and 15 between ages 1 and 2 years implanted in 2005, and, in 2007, the implantation of 17 children less than 12 months old and 29 between ages 1 and 2 years. (Figure 1 shows implantation data by year from 1988 to 2007.)
The use of cochlear implantation for persons with a hearing loss in Norway also reflects the process in other developed countries. The first person to receive a cochlear implant in Norway was an adult fitted in the city of Trondheim in 1985. Nineteen other adults received implants from 1985 to 1989. The first postlingually deaf child was implanted in 1988 at 6.5 years of age at the Rikshospitalet (the National University Hospital) in Oslo. This individual was believed to be the first child implanted in Europe with the Nucleus 22 prosthesis. The following year, the first prelingually deaf child was implanted, at 8 years of age. Subsequently, the child did not benefit from the implant and became a nonuser. In 1992, a 3-year-old prelingual deaf child was implanted, then educated in a bilingual program, as was the standard practice at the time. The child remains a consistent user of the device. To date, the youngest child implanted in Norway was 5-1⁄2 months old. Between March 1988 and December 2006, more than 300 children were implanted, and by December 2007 a total of 364 children had received an implant. In contrast to the situation in some countries, all implant surgery on children is done at one hospital, the Rikshospitalet. Other hospitals in Norway, in Bergen and Trondheim, perform implantations, but only on adults. Children assessed for implantation at the Rikshospitalet include individuals with severe as well as profound hearing loss, and some with additional disabilities. Bilateral implantation is available if considered anatomically and audiologically feasible. Parents have a choice of either the MED-EL or the Nucleus device. The process of implantation (including assessment, surgical procedures, acquisition of the prosthesis, and postimplant mapping and therapy) involves no cost to parents.


Figure 1 shows a pattern of slow increases in child fittings from 1988 to 1998, with acceleration beyond 1999. The annual data for 2003 and 2004 (the latter reported in January 2005) reflect little change in the ages of fitting, with 33% of children being implanted between ages 2 and 3 years in 2004 and 35% in 2003, and in 2006 and 2007 a majority under the age of 1 year. As indicated, the national implementation of UNHS continues to influence this pattern toward younger ages of fitting.







The Education System for Deaf Children and Their Families in Norway The French pedagogical system for educating deaf children was imported into Norway via Denmark around the start of the 19th century. In 1825, the first school for the deaf, based on the use of sign language and employing both deaf and hearing teachers, was established in Trondheim, in central Norway.
In 1848, the “German method based on oral training, was introduced at a new private school for the deaf in the Norwegian capital, Christiania (later Oslo). The well-known rivalry between manual and oral educational methods took its specific turn in Norway after 1850. Both the manual and oral schools were regarded as successful, which led to some satisfaction but also to further aspirations among politicians, the public, and professionals.
In consequence, in 1881 Norwegian lawmakers enacted specific, ambitious, and progressive legislation on education for all deaf children. Embedded in this law (the Abnormskolelov, “legislation concerning the education of abnormal children”) was the conviction that the “abnormality” of deaf children or deaf people in general was primarily related to the exceptional educational methods required in their development and education. According to the Abnormskolelov,
both the manual and oral communication methods were to be applied in schools, with the restriction that each school was not to use more than one method (Simonsen, 2000).
The progress of the system of schools for the deaf in Norway through the 19th and 20th centuries can be characterized as following international trends, with severe limitations on the use of manual methods and sign language following the Milan Congress of 1880 and a “new” rise of oralism in the mid-1900s under the influence of members of a British family of scholars, the Ewings (I. R. Ewing & A. W. Ewing, 1954, 1958; A. G. W. Ewing & E. C. Ewing, 1964), and, in the Netherlands, of Henk Huizing’s “acoupedics” (Power & Hyde, 1997). Oralism remained dominant until the decade between 1970 and 1980, during which national law and policy were reformed (Simonsen, 2005).
Following this period, optimism developed regarding the value of bilingual education of deaf children,
and efforts to develop specific curricula adjusted to the needs of deaf children followed. By the end of the 1990s, bilingual education and the schools for the deaf using this approach were flourishing, supported by legal protection of children’ right to access to bilingual education by means of Norwegian Sign Language, or NSL, per Section 2-6 of the Norwegian Education Act of 1998. An increasing number of deaf children  divided their learning time between their local school and a school for the deaf. A free 40-week educational program for teaching parents and families basic sign language and knowledge about deafness, Se mitt språk (See my language), has been offered since 1995. The political, legislative, and educational structures used in Norway for deaf children and their families are different from those in other countries and even have specific differences from the systems used in other Nordic countries.
A national state support system for children with special educational needs was established in 1992, with its main objective being to assist families, local schools, and municipal authorities in their efforts toward inclusion of children with special needs in local schools. The national support system consists of 15 resource centers
funded by the state and 25 associated centers funded independently or by other means. Among these are six resource centers for deaf and hard of hearing children, each with a school for the deaf and itinerant advisory services.
These centers offer supervision and guidance for individual children and their families as well as programs for municipalities, local schools, and child guidance services. One of the centers, the Skådalen Resource Center, has a specific research unit. Both the Skådalen Center and some of the other centers conduct research on
deaf education in close collaboration with universities in Norway and abroad, with the intention of monitoring the national system of education for deaf students and promoting effective change. The research reported in the present article is one such outcome.
Over the last decade, two principal discourses on the education of deaf  children with a cochlear implant have emerged in Norway, as they have in many other Western countries: a cultural- bilingual discourse and a medical– cochlear implant discourse. Both leave limited scope for an arguably more salient discourse on distinct educational issues (Simonsen & Ohna, 2003). The assumed dichotomy between these two reigning discourses leaves education in a somewhat restricted position at a critical time when issues of pedagogy and curriculum should be primary focuses for researchers and practitioners (Hyde & Høie, 2007).
According to Section 2-6 of the Norwegian Education Act of 1998, parents may decide whether or not their deaf child should be in a program of bilingual education with NSL added as a language of instruction and communication.
Specific syllabuses for educating students in such programs were developed during the 1990s. As such, Section 2-6 may be implemented in special classes or in local schools across the districts of Norway.
In 2008, Section 2-6 was revised. Under this revision, a strictly defined bilingual educational program was no longer required for access to sign language in deaf children’s education. Any child with an educational need to learn and be taught through sign language will now be entitled to have that need met, regardless of how his or her educational program or school is categorized.




The choice of educational approach,
communication mode, and
language (or languages) used is dependent
on the parents’ judgments
about the educational needs of their
child, particularly their wishes in relation
to the preferred modes of communication
applied in classrooms.
Their decision is usually made in a
context of counseling and support by
an interdisciplinary professional team.
What is unusual in an international
context is that the right to bilingual
education for a deaf child is not dependent
on audiological criteria, but
on the assessment of communicative
and educational needs. It remains to
be seen how long this context of decision
making based on communicative
and educational evaluations will last.
The new potentials, both real and
perceived, presented by the earlier
detection of hearing loss and the impact
of greater levels of implantation
of infants with severe and profound
hearing loss are creating challenges to
current educational policies and practices
directed at achieving inclusion in
a context of bilingualism. Tensions are
evident among practitioners, parents,
and associations of deaf and hard of
hearing people. Using two national
projects conducted over the last
decade by the Skådalen Resource
Center as a focus, we attempt in the
present article to update the situation
of Norway in respect to the implications
of cochlear implantation for policy
and practice.
Research on Inclusive
Education of Children
With a Cochlear Implant
in Norway
The first of the two national studies,
“Children With Cochlear Implants”
(conducted from 1999 to 2001), examined
the communication conditions in
the learning environments of 43 deaf
children in kindergartens and primary
and upper secondary schools (Christophersen,
2001; Hjulstad, Kristoffersen,
& Simonsen, 2002; Landsvik 2001; Simonsen
& Kristoffersen 2001; Strand,
2002). The children in kindergartens
varied in age from 3 years to 5 years 6
months. The age at which the children
received their implants varied from 2
years 6 months to 5 years 1 month,
with an average age of implantation of
3 years 2 months. According to
parental reports and school records
(based on information provided by
parents), 20 children were considered
prelingually deaf and 4 postlingually
deaf. The 19 children attending school
ranged in age from 6 to 19 years.
This qualitative study included interviews
with children with a cochlear
implant, their parents, and their teachers;
videotapes of interaction patterns
in classrooms and kindergartens; and
related field notes. Analyses of the
recordings of children’s access to
classroom communication showed
major variations among the kindergartens,
schools, programs, and professionals
participating in the study
(Hjulstad et al., 2002). Assessment of
interaction and participation patterns
demonstrated correspondence with
the modes of communication that
were applied, in the sense that educational
settings that offered a range
of cultural tools, including both sign
language and spoken language and
an array of flexible and adapted approaches
to communication, represented
beneficial environments for
attaining higher levels of student inclusion
and participation in classroom
activities (Hjulstad et al., 2002). In
educational settings where spoken
Norwegian was used, access to communication
and interaction was restricted
in many cases, including
collective learning processes in groups
and participation in classroom instruction
and associated peer interaction.
Parents’ responses demonstrated expectations
more in line with their children
achieving an appropriate level of
“participation,” primarily in school
and family life, rather than expectations
of “excellence,” particularly with
the use of spoken language (Strand,
2002). As for the children themselves,
the nine primary school children who
were interviewed were able to convey
an impressive metacomprehension of
their communicative situation and the
strategies that they used to participate
(Christoffersen, 2001).
The second study of educational
settings for children with a cochlear
implant, “Inclusive Education of Children
With Cochlear Implants: A Follow-
up Study,” was undertaken from
2004 to 2007. This was a study of the
same 24 children with a cochlear -
implant in kindergarten included
in the earlier national study (“Children
With Cochlear Implants,”
1999–2001). These former preschool
children were tracked in their lower
primary-school settings (Simonsen,
Kristoffersen, & Hjulstad, 2008). A
majority of the 24 children had been
placed in their local schools, while
some had been placed in special
units or special schools for the deaf.
School placement, however, was not
representative of educational programming
in Norway, as bilingual
programs can be identified in all of
these settings. However, programs
using spoken Norwegian as the single
communicative tool are only to
be found in local schools. The main
purpose of the follow-up study was
to generate knowledge from the educational
practices that were observed
and reported. There were three research
questions:
• What kinds of linguistic resources
are available and in
use in the interactions between
teachers and children in the activities
in classrooms?

• What are the opportunities and
constraints in regard to learning
and participation within the different
educational practices that
are observed?
• How do schools regard the
learning environment for students
with a cochlear implant?
Sample and Procedures
The children in the 2004–2007 followup
study are now generally regarded as
cochlear implant “pioneers” in Norway.
Recipients of implants in the period
1996–1999, they represent about 70%
of the total population (35) of preschool
children implanted up to 1999.
The follow-up study included 10 girls
and 14 boys from both rural and urban
areas in Norway. In addition to the diversity
within the group in terms of
age, school type, education program,
degree of hearing loss, and curriculum
category chosen, there was also considerable
diversity with respect to how
classroom communication and participation
were organized, regulated, and
maintained. This involved variations
among the modalities (speech, sign,
and speech with sign) that were used
and between the two languages in use:
Norwegian and NSL.
Data were collected during the
2004–2005 academic year. The children
then ranged in age from 7 to 11
years, attended school grades 1–5,
and varied in regard to duration of implant
use from 5 to 8 years. The educational
placements of the students
included local schools (15), schools
for students who are deaf or hard of
hearing (7), and local schools with
separate units for deaf children (2).
The curriculum categories chosen by
parents were bilingual education (as
defined in Section 2-6 of the Education
Act of 1998), special needs education
(per Section 5-1 of the Education
Act), and local schools using only spoken
Norwegian. We report some findings
from the initial study and the follow-
up study in the present article to
demonstrate the patterns of communication
and language use that
emerged.
The data from both the initial study
(1999–2001) and the follow-up study
(2004–2007) consist of field notes of
classroom activities and interactions,
the products of children’ activities
(mostly written materials), and classroom
organization and teaching materials.
The observations were based on
multiple audiovisual recordings of different
forms of classroom talk and the
interactive events and contexts in
which they occurred. Two cameras on
tripods were used with an external microphone.
Transcripts were made of
the recorded classroom activities,
with note being made of lesson or activity
type, the participants involved,
the classroom organizations, the nature
of the discourses that occurred,
and the communication modes and
language forms that were used. Interviews
with teachers and principals
were audiorecorded and transcribed.
The audiovisual data consisted of approximately
60 hours of recordings,
and the audiorecorded interviews
approximately 50 hours. Additionally,
we rated each student on the
Categories of Auditory Performance
and the Speech Intelligibility Ratings
(O’Donoghue, Nikolopoulos, & Archbold,
2000). These data are presented
in Tables 1 and 2.

 

The two tables show increasing    rates of auditory perception and speech intelligibility for most of the children across the study period. 

Some Characteristics of  the Use of Modalities in Classrooms The 2004–2007 follow-up study involved two methods and related analyses. The first method entailed an examination of interaction patterns based on a conversation analysis focused on understanding the nature of situated learning in local school and special classrooms in which the deaf students with a cochlear implant were enrolled (Hjulstad & Kristoffersen, 2007). The second method entailed interpretations of the statements of the experiences, pedagogical principles, and practices reported by education staff, including teachers, sign language interpreters, teacher assistants, and principals (Simonsen et al., 2008). 

To describe a “typical” classroom in our study is complex. When categorizing  the classrooms according to their use of a particular communication modality during classroom activities, we identified five different patterns (see Table 3).

While the various patterns of use were not employed in all activities in the particular schools involved, they do offer evidence of the diversity of ways in which communication and language issues were operating. There was no common causal explanation, and the observed diversity is seen to be an outcome of the various interpretations that are possible under national legislation and policy in Norway concerning deaf children; the choices that parents, schools, and teachers make; and the devolution of many of these decisions to local school districts serving the needs of deaf children within their existing resource base. Thus, there may be considerable diversity within schools even though a particular pattern of communication is in apparent use at any specific time.

Any expectations that classroom practices would be in accordance with the conventional labels assigned to the education of deaf students were not found in the two national studies. 

On the contrary, the analyses show that local classroom practices with local and pedagogical adjustments to the perceived needs of individual children were the pattern. In this Norwegian context, the notion of fixed educational programs in conventional terms of “oral education,” “bilingual education,” or “Total Communication” makes little sense. This finding suggests that other national or comparative studies of the classroom experiences of deaf students with a cochlear implant may prove productive in revealing what diversity exists among the comunication and curricular practices used in schools and associated local interpretations of national policies (see also Knorrs, 2007).

Educational or Instructional Patterns

In examining the local schools, in which a student with a cochlear implant will usually find himself or herself the only such student in a class of hearing children, we found indications that some teachers’ choices of communication mode and language were guided by their perspective that all children should be able to participate in the classroom discourse. 

Other teachers, however, seemed to be led more by directions from medical advisers or by parents regarding which communication mode to apply. Here, differences between mixed-modality classrooms may, to some extent, be influenced by the child’s degree of hearing loss and perceived competence in a particular language. An interesting and perhaps more important finding is that different instructional activities appear to

create different challenges with respect to participation by the child with a cochlear implant, but the availability of different communication modalities offers potential for enhanced participation. 

For example, the use of sign and speech at the same time is more common in teacher-directed plenary lessons, in which a teacher who is bilingual addresses both the bilingual

deaf student and the hearing students at the same time.

Whole-class conversation was less teacher directed, and all children were communicatively more active. This often created a more demanding discourse for children with a cochlear implant; further, the teachers more frequently used sign and speech at the same time in their contributions, and interpreted peers’ speech-alone contributions into sign-alone form for the deaf student. We termed this kind of mode and language mixing participation- related modality alternation. 

Other kinds of activity were less demanding for the participant with a cochlear implant, for example, seat work, when teachers often used speech alone in communication. Even here, teachers mixed languages and modes in different ways in different situations, for example, during the explanation of certain concepts, clarifications, or other situations occurring in a specific context.

At the study sites there were also instructional activities that were interpreter mediated rather than teacher mediated, and classes in which most hearing students were reasonably proficient in NSL. These activities further demonstrated the variety of communication modes and mixing of language forms according to the perceived needs of the child with a cochlear implant, the other participants, and the activity in question.

In the bilingual classrooms (those for which students’ parents had chosen to adhere to Section 2-6 of the Education Act of 1998 and its provisions), we observed that the goals and purposes of the teaching of children with a cochlear implant were not necessarily about maintaining NSL as their first language, as it was possible that the language learned first was no longer a student’s most frequently used language in school or at home. This was the case for many of the children we studied, in instances in which Norwegian in spoken and written forms remained in active use in classrooms.

Teacher Statements

The findings reported in the present article do not constitute the entire set of findings from the two studies (Hjulstad et al., 2002, Simonsen et al., 2008); however, we present them to demonstrate the contextualizing influences of national legislation and policy, local school practices, teacher knowledge, and parental choices about the educational experiences of children with a cochlear implant.

The teachers generally reported a pragmatic approach to the use of linguistic forms in the classroom. Choices were based on the nature of the learning situation and the relational aspects involved. The legal framework of the education of each student, whether it was bilingual education per Section 2-6, special needs education per Section 5-1, or simply ordinary adjusted education, was not a precise indicator of the actual educational practices of any classroom, as noted earlier in the present article. This outcome was explained by teachers as resulting from practicalities such as access to specific language competencies and resources and associated economic resources, as well as being a consequence of the pedagogical freedom and sovereignty of the local school and the individual teacher.

The educational practices reported by the teachers in the follow-up study seem to indicate one of two different profiles among the teachers, reflecting their professional position in regard to the children with a cochlear implant: a sense of either independence or dependence. 

The first group of teachers reported that they encouraged the children to speak and communicate in whichever language and mode was most functional and could be comprehended by the participants in the particular activity. None of these teachers were dissatisfied if, for example, the child with a cochlear implant used speech more than sign or sign more than speech. This was simply regarded as part of the process of becoming capable of participating and communicating within different communities of language users and a consequence of being a bimodal, bilingual learner. Further, it did not necessarily suggest the primacy of either language, or indeed the child’s progression away from bilingualism and toward spoken language.

These teachers viewed the emerging bimodal bilingualism as a characteristic of these young cochlear implant pioneers, many of whom were introduced to sign language before receiving their implants.

The second group of teachers, who may be identified as more dependent on external authorities in regard to their responsibilities toward the child with a cochlear implant, reported strong external influences and expectations at work, including those of parents, providers of educational and psychological services, resource centers, and the cochlear implant team at the national hospital. While these external agents might agree, often they did not, placing these teachers in a difficult position.

The main disagreement that was reported was over the language mode to be applied in the school. When both visual and auditory languages were allowed, the tension levels were reported as being low and allowing for diversity in instruction and adapted education.

In the cases in which spoken Norwegian was the only language permitted, tension levels were reported to be higher. Some of the teachers in this latter situation described feeling squeezed between expectations and reality, and said they had difficulty meeting the demands of their classrooms: “We try not to use sign language in class—but it is hard”; or, “I realize when he does not understand what is being said. Then we have to use our hands.” The increasing complexity of the subjects taught in primary and secondary schools, combined with the demand for higher levels of literacy, with the resultant increase in problems providing access to communication in classrooms, was creating anxiety for several of these teachers.

The gap reported by these teachers between governmental, parental, and societal expectations of cochlear implantations and their own perceived realities of the education of these children may be interpreted as a problem of bridging between, on the one hand, bilingualism, special needs education, and adjusted education as legal and political concepts in Norway, and, on the other hand, the complex and diverse communicative and educational needs of deaf children with implants. It may be said that one outcome of the 2004–2007 study was the strong conviction among teacher participants that a need exists for more studies of students with a cochlear implant in various school and classroom contexts that may reveal the complexities of communication patterns and language mixing across a range of curricular activities. Such studies could lead to a better understanding  that effective communication may enhance participation as a part of the learning processes of the classroom, and counter the perception that participation should be viewed as an end in itself.

Conclusion 

Norway is a country with a relatively small population but strong historical and social traditions directed toward national independence and inclusion of all its citizens in education. The trends noted for the early detection and incidence of hearing loss among young children and the early use of cochlear implants largely parallel those observed in other developed nations. An exception, to date, has been that the child’s degree of hearing loss has not been a critical factor in the determination of school placement, the right to bilingualism, or curriculum choice.

What is demonstrated in the findings reported in the present article and in the description of the Norwegian system for the education of deaf children is that specific national legislation, local responses to policy implementation, traditions about the recognition of languages, and the use of teacher judgment in classrooms can all significantly influence the everyday experiences of deaf children with a cochlear implant. In particular, a diversity of communication practices and outcomes is revealed that may be seen as participatory and inclusive in the relevant educational settings and learning contexts. In terms of communication, these practices and outcomes involve the use of spoken Norwegian and NSL as well as the discriminating use of various language forms and modality mixing in classroom learning activities.

Although Norway has strong and well-articulated legislation, traditions, and policies in the area of bilingualism for deaf children in inclusive education contexts, these contexts are now being challenged, and pressures for reform of service systems are evident.

There are tensions and pressures associated with changing expectations on the part of some parents and professional and community groups about the implications of earlier detection of hearing loss through UNHS and earlier cochlear implementation of deaf children.

These major changes and the opportunities that they present are placing current policies and practices in a critical perspective. Expectations by some parents and professionals of outcomes that are not clearly associated with children’s development of bilingual competence and identity are a source of tension and debate among stakeholders. 

While the early detection of hearing loss and the implantation of younger deaf children are of major significance and benefit for all concerned, the need to consider the diverse outcomes that these developments may have for individual children in classrooms across the country and in their postschool life remains paramount. In this context, the experiences reported with cochlear implants in Norway may be described as complex but not necessarily confusing. Many teachers of these deaf students seem able to focus on classroom learning, using a variety of tools of communication and learning. This capacity makes the flexibility that is provided for in current legislation and policy a major asset of this national system.

In any reformation of policy and practice, it is essential that the perspectives of teachers, the pedagogies they use, and the realities they face continue to be a focus in studies of learning by deaf children in classrooms.  

Teachers and other classroom practitioners represent a unique source of knowledge for research on the educational needs of children with a cochlear implant (Thoutenhoofd et al., 2006). In particular, there is an urgent need for school achievement data on students with an implant using, for example, some of the methods employed in the study of the educational achievements of deaf students in Scotland by Thoutenhoofd (2006). Tapping this pool of knowledge and combining quantitative data on demography and large-scale educational attainment data with ethnographic approaches and classroom studies on the micro level may lead to increased understanding and reveal the subtleties and complexities involved in cochlear implantation in early childhood and in education. The object of such research would be the intrinsic and dynamic ways deaf students make use of languages for interaction with their environment in the learning processes. 

What the current situation in Norway— as exemplified by the two national studies discussed in the present article—seems to imply is the possibility of a unified rather than a dualistic or divided perspective on the national future of deaf education, provided that both visual and auditory modes of communication and the languages they may form are perceived not as oppositional but as complementary.

In this sense, “excellence,” as we note in the opening section of the present article, would be a marker of the quality of the learning environment and an indicator of the degree of access to communication for all students— not a referent to any single language form or communication mode.

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12(2), 209–220. VOLUME 154, NO. 3, 2009 AMERICAN ANNALS OF THE DEAF

273

Research into Family perceptions of Cochlear Implants

Cochlear Implant/Bionic Ear Research

  

A comparison of Anticipated Benefits and the Personal, Educational and Social Outcomes of Cochlear Implantation in Deaf Children

ARC Linkage Research Project LP0562224

This research project, commenced in 2006 and funded by the Australian Research Council with support from Deaf Children Australia as industry partner, has now completed its data collection and analysis stages and the results are being compiled for publication. The original investigators were Dr Linda Komesaroff, Faculty of Education, Deakin University, Professor Merv Hyde, School of Education and Professional Studies, Griffith University, and Professor Mirko Bagaric, School of Law, Deakin University. In August 2007 Dr. Renée Punch joined the project as a Senior Research Fellow. This report was prepared by Professor Merv Hyde and Dr Renée Punch.
Ethics approval and support for the conduct of the study were provided by a number of education departments, cochlear implant programs, and other organisations that participated in the study; these are indicated in the Appendix. Significant interest in the study is already appearing in national and international forums. To date, one paper has been presented at a conference in Norway and another is scheduled for presentation at the Mental Health and Deafness conference in Brisbane in October. Currently, seven individual papers are in preparation for publication in international journals.
The following constitutes a plain language statement summarising the focus of the study and its findings.

Description of the study
The study investigated three major aspects of childhood cochlear implantation: 1) the expected outcomes of implantation; 2) families’ decision-making process; and 3) the personal, social, and educational outcomes of cochlear implantation for deaf children and their families. It examined these areas with a relatively large sample of parents, teachers, and young cochlear implant recipients across a range of locations in Queensland, New South Wales, and Victoria. It included children with varying lengths of time since their implantation and thus gained the perspectives of the parents, teachers, and children about the lived experience and functional outcomes for implanted children and their families over time.

The parent survey contained three sections. The first collected demographic data about the children and their families. The second contained questions about the parents’ experiences of making the decision to implant their child. The third contained five subscales asking parents to indicate their pre-implantation expectations and post-implantation experiences of their children’s outcomes. These subscales were 1) Communication Abilities, which reflected abilities in spoken language in functional, everyday situations; 2) Social Skills and Participation, which was concerned with children’s acceptance by hearing peers, social participation with children in general, and having improved social skills; 3) Wellbeing and Happiness, with items about children’s happiness, frustration, and safety with the implant; 4) Academic Achievements, including children’s ability to participate in regular classes and items concerning levels of achievement in numeracy and literacy; and 5) Future Life, with items about children’s general functioning and independence as well as their identity as deaf or hearing persons.

The teacher survey asked teachers to report on outcomes in the same domains as on the parent survey, with the exclusion of the Wellbeing and Happiness subscale, which contained items specific to parents’ knowledge of their children. An additional section of the teacher survey assessed the level of participation of children in their school and classroom activities in four areas: academic, social, independence, and physical presence in the regular classroom.
The study utilised a mixed methods approach that allowed the quantitative survey findings to be extended and elaborated by qualitative findings from in-depth interviews and open-ended written responses. This combination of methods proved to be efficacious in not only revealing the specific quantitative details in answer to the research questions, but also increasing the relevance of the quantitative findings by enabling a deeper understanding of parents’ and children’s implant experiences through the analysis of the qualitative data.

Participants
Surveys were distributed to parents of children who had received cochlear implants before the age of 18 and to teachers working with deaf children in early intervention programs, primary schools and high schools. Each teacher and early intervention specialist supporting children with cochlear implants was asked to complete a survey based on one randomly selected child whom they supported. Completed surveys used in the analysis numbered 247 for parents and 151 for teachers. The children reported on in the surveys had a range of ages, age at implantation, and duration of implant use. Almost 90% of the parent survey respondents were mothers. Despite sustained efforts to include parents who were Deaf, only one survey respondent was a Deaf parent.
Approximately 10% of the respondents in these two groups were interviewed: 27 parents and 15 teachers. In addition, 12 implant users, aged between 10 and 17 years, have been interviewed.

Making the decision for cochlear implantation
The quantitative findings indicate that, in making the decision for their children to have cochlear implants, parents used a range of sources of information, most especially cochlear implant programs, audiologists, and doctors, with these sources being followed in importance for parents by families of children with cochlear implants. Relatively few parents used deaf organisations or deaf adults, with or without cochlear implants, as information sources. In the interviews, many parents expressed a wish to have received information on a broader range of subjects, including social and educational aspects and communication methods, than was readily available to them at the time of making the decision.
The majority of the parents reported that making the decision to have their child implanted was stressful and difficult. However, a sizeable group of parents reported otherwise. These parents tended to decide quickly, usually because they felt that an implant was the “only way” their child would gain communication through speech and hearing, and so was the only option for their child. Overall, the decision-making period was quite short, with 60% of parents taking less than three months to make their decision.
Parents generally found making decisions about having a second, bilateral implant for their children more difficult than the first, being concerned that possibly marginal gains might be outweighed by disadvantages.

Parents’ expectations and experiences of children’s outcomes
The study compared parents’ reports of their pre-implant expectations with their experiences of post-implant outcomes on a large number of items related to the five outcome domains. The quantitative findings indicate that this group of parents as a whole had held relatively high expectations of their children’s communication, social, academic, wellbeing and future life outcomes from cochlear implantation. They also indicate that the parents’ experiences of their children’s outcomes with their cochlear implants were relatively high. There was quite a close match between expectations and experiences, and where there were high levels of uncertainty in expectations, these were informed by experiences, usually in a positive direction. There were particular outliers from this general conclusion in the academic achievements domain, particularly in the case of achievements in literacy and numeracy, where parents’ uncertainty about possible outcomes moved in both directions with experience, but with more parents indicating a move in a negative direction than was found in the other domains. This is obviously of concern.
Of responses to questions about overall satisfaction, four fifths of the parents indicated that their expectations had been met. These findings suggest that the majority of parents had high levels of satisfaction with their children’s outcomes with their cochlear implants. Nevertheless, a proportion of the parent group did not indicate satisfaction. For example, a tenth of parents reported that their overall expectations had not been met. Further, a tenth of parents were not currently satisfied with their children’s communication abilities, social skills, and academic abilities. These findings are consistent with those of other studies in which between 5% and 20% of parents have reported unmet expectations.
From the qualitative findings, it is clear that parental expectations were closely intertwined with parental hopes. The findings suggest that parents’ expectations, hopes and beliefs about cochlear implantation may more accurately reflect the love they have for their child, the determination they have to do the best for their child, and their conviction that a cochlear implant is the only way for their child to most fully participate in a hearing world, than arise from the range of outcomes explained to them by professionals. Parents tended to interpret such explanations in the most positive context.

Comparison of parents’ and teachers’ experiences of children’s outcomes
There were statistically significant differences between teachers’ and parents’ reports of children’s outcomes on the four domains common to both the parent and the teacher surveys, (communication abilities, social skills and participation, academic achievements, and future life) with teachers reporting lower levels on all four subscales. As noted above, the strength of parents’ hopes for their children and their emotional investment in their children’s implantation could have led to generally more positive perspectives of the outcomes than those held by teachers. However, although parents and teachers were reporting on children drawn from the same population (i.e., children who had been implanted in NSW, Victoria and Queensland), these two groups of respondents were not necessarily reporting on the same children in each case.

Communication outcomes
Spoken language communication abilities were reported to be relatively high by parents and somewhat lower by teachers. Some children were developing, or had developed over a period of years, near normal speech and language outcomes, but these tended to be in specific situations involving familiar communication partners, such as family members, and in familiar contexts and optimal listening environments. In broader contexts, such as in regular classrooms and in social groups and gatherings, the picture is not as positive, with parents and teachers reporting difficulties for children in these environments.

Social outcomes
In the survey subscale of social skills and participation, parents indicated relatively positive outcomes for their children. However, the qualitative findings reveal that the area of their children’s social skills and participation remained a concern for many parents, who were aware of their children’s difficulties in groups and how those difficulties affected their social inclusion. For many parents, worries about social participation increased as their children reached adolescence and appeared to struggle with issues around being deaf and fitting in with hearing peers. In addition, findings from both the quantitative and qualitative teacher data indicate less than optimal social outcomes. It appears that even children with excellent outcomes in spoken language development and communication experience the phenomenon of “social deafness.”
Overall, it seems that issues around friendship and fitting in with hearing peers were as real for these children with cochlear implants as for other deaf or hard of hearing children for whom these social problems have been reported in the literature.

Academic outcomes
More than two thirds of parents reported that their children were able to participate easily in a regular class, and slightly more than one third of teachers reported this. Between 50 and 60% of teachers disagreed that children were achieving high standards in reading, writing, and maths, or were achieving at the expected level for their age, whereas between 18 and 23% of parents indicated disagreement on these items.

Wellbeing and future life outcomes
In areas of children’s general functioning, independence and identity as deaf or hearing persons, the large majority of parents believed their children were happier, less frustrated, and safer than they would have been without the implant. Almost 60% of parents believed their child functioned like a child with normal hearing, whereas only 30% of teachers reported this. Close to 30% of parents and teachers believed the child had developed an identity as a deaf person, while two thirds of parents, and slightly more than one third of teachers, reported that the child comfortably shared both deaf and hearing identities.

Impact on the family, parental stress and rehabilitation demands
A statistically significant difference was found between parents’ expectations and experiences on the rehabilitation stress subscale of the survey, with parents experiencing more stress than they had expected pre-implantation. In addition, living in an outer regional or remote location was found to predict higher levels of parental stress. A major theme in the qualitative findings concerned the amount of work and time parents dedicated to their deaf child in the areas of early intervention and speech training as well as in terms of frequent appointments for mapping and other ongoing requirements related to the use of the cochlear implant. They reported feeling stressed by the time needed to travel to and attend appointments, and by the difficulties this imposed on their other children and on the family’s financial situation.
The extent and quality of support in practical, functional ways was an issue for many parents. Parents described frequent problems with implant equipment breaking and parts needing replacing. When these could not be replaced quickly, it was worrying for parents and difficult and frustrating for their children to be unable to use their implant and thus be without their means of hearing, sometimes for several days in the case of families living long distances from appropriate services. It was clear in our interview findings that parents greatly appreciated when replacement parts, loaner speech processors, or repairs were delivered expeditiously.
Parents whose children did not do well with the implant and whose speech and language development was poor clearly went through particularly stressful periods. In cases where auditory-oral approaches were not proving effective and parents moved towards using sign, they often lost a valuable support base if they were unable to continue attending the same early intervention centre.

“Still deaf” and the role of sign language in the children’s lives
The quantitative findings indicated that parents overwhelmingly chose cochlear implantation for their children as a means to develop communication through hearing and speaking, and that parents’ expectations in the main were that their children would not need to need to use a sign language or sign support. However, experience would seem to have tempered this perspective to some extent and a substantial proportion (between 20% and 30%) of children were reported by both teachers and parents to be using some form of sign communication.
The qualitative findings elaborated on these findings, providing details of ways in which children were using sign and of parents’ views about sign communication. The interview findings showed that many parents, despite facing, at times, strong discouragement from early intervention centres and cochlear implant clinics, had become convinced of the benefits of sign language for their children. These parents saw the value of developing communication with their children through sign language so that they could communicate whenever the children were not wearing their implants’ external device, whether because of equipment breakdown, or when the children were in situations where it could not be worn, such as swimming. Some parents also valued Auslan as a way for their children to establish a connection to other deaf people and a sense of Deaf identity, or of a dual, Deaf/hearing, identity. However, the issue remained relatively unclear for the majority, and is a worthy topic for future study.
Parents often used the term “still deaf” to describe their children. They, and some of the teachers interviewed, asserted that many people, including regular class teachers and school authorities, had misconceptions about the nature of cochlear implantation and did not understand that the children still experienced limitations to their hearing, difficulties managing in many auditory environments, and delays in aspects of their development that necessitated ongoing support and accommodations in the school setting.

Factors predicting outcomes
Through multiple regression analysis of the parent and teacher survey data, a number of key predictors were identified. Some of these were associated with perceived positive and some with perceived negative outcomes. Among the large number of variables related to family and child characteristics, educational and communication factors, and the parents’ implant decision-making process entered into the series of step-wise regressions, a number were found to be consistently associated with children’s outcomes in the areas of the subscale domains.
Several variables related to oral communication and mainstream placement were shown to predict positive outcomes in many of the domains in both parent and teacher survey findings. This could be explained by sign language programs being largely associated with late diagnosis and the presence of additional disabilities, as well as the scarcity of comprehensive bilingual programs outside metropolitan cities. This combination of factors means that many of the students determined to require access to sign language or signed English were in fact placed in special education rather than regular class programs; in these contexts a high standard of oral communication outcomes is not the norm.
Consistent with other studies, a younger age at implantation was found to be a predictor of positive communication and social outcomes. The child having a bilateral implant was predictive of positive communication, social, and academic outcomes in parent reports and of future life outcomes in teacher reports, noteworthy findings adding to the still relatively limited knowledge of broader outcomes of bilateral paediatric implantation.
The child having additional disabilities was strongly predictive of less positive outcomes in all domains in both parent and teacher reports.
The regression findings also indicated that families’ location in major city areas was associated with positive communication outcomes, and that living in regional or remote areas predicted greater rehabilitation stress for parents. In addition, teachers having high levels of communication with other professionals, such as audiologists and speech pathologists, about the child’s use of and progress with the cochlear implant predicted positive outcomes in all domains. Some variations across States were found, with teacher data showing that being in Victoria was associated with higher academic achievements and being in Queensland was associated with less positive communicative and social outcomes. These differences may reflect differences between the states’ systems and programs. Although programs providing Auditory-Verbal Therapy (AVT) are of recent origin in all states, NSW and Victoria have long traditions of auditory-oral programs in both preschool and primary school settings. This has not been the case in Queensland, and indeed, children who were not in special education settings were placed in the mainstream. The advent of the Hear and Say Centre in Queensland has, of course, added an option The variations may also reflect the geographical dispersion of families, with some of the study participants in Queensland living at far greater distances from urban centres than families in Victoria. Further inquiry from the perspective of research and evaluation of current programs is required to elaborate on these differences.

A number of practical implications were drawn from the study:


Implications for cochlear implant programs
Implant programs should continue to advise with caution about the range of likely outcomes but also be aware that families are likely to be influenced by their hopes and aspirations for their children as much, if not more, than by the information they have received. Consequently, information giving and receiving processes should be regularly repeated and evaluated through ongoing discussion and counselling. As well, the important role played by hope needs to be recognised, as parental hope and optimism can drive the action, determination, and hard work that contribute to children’s progress and optimal outcomes from their cochlear implants. There seems to be no evidence in the literature that excessive hope is ever a ‘bad’ thing. Professionals, however, in implant, therapy, and educational programs need to find the difficult balance between working with parents’ hopes to achieve optimal outcomes and ensuring parents have realistic expectations of their children’s cochlear implantation.
For children to receive optimal benefits from their implants and for the demands and stress on parents to be reduced, it is necessary that continuing efforts are made to improve access to audiological, habilitation and ongoing device maintenance services for families who live in regional or remote parts of Australia. The trans-disciplinary ‘case manager’ approaches and outreach initiatives which several Australian states have been adopting following the introduction of newborn hearing screening have strong potential for offering non-biased and comprehensive support for families as they make decisions and monitor the progress of their child. However, these state systems need to access the full range of support and information services available to parents including, not only audiological and educational intervention services, but also parents’ support organisations and social and cultural organisations representing the various perspectives of deafness
In this context, it may be important for information about sign language and the Deaf community to be more accessible to families both before and after their children’s implantation, and for parents to be made aware that choice of a communication mode need not be an either/or option. In other words, sign language exposure and bilingualism is not solely something to be resorted to if children fail to develop oral-oral communication proficiency, but can be used to provide fuller access to cognitive development and communication competence across a range of situations and settings maximising the child’s life experience and potential.

Implications for support services/counsellors
It is important for service providers to sustain and encourage parents’ hopes and to respond with flexibility when children’s and parents’ needs change over time, particularly when expected outcomes are not achieved and it becomes apparent that alternative strategies and approaches are necessary.

Implications for early intervention providers and education authorities
From the perspective of their functional communication, children with cochlear implants should be supported by teachers and school authorities as if they were hard of hearing; that is, the children are likely to need supports similar to those provided to children with moderate or severe levels of hearing loss. This is not to suggest that their hearing status or spoken language capacity and proficiency is not high, but that they are likely to have listening difficulties in particular contexts and will not have full access to the curriculum or to social inclusion.
It is apparent from the findings that ongoing, high levels of communication between teachers and other professionals contributed to positive outcomes in all areas of the children’s lives. Given these findings as well as the finding of differences between parents’ and teachers’ perceptions of children’s outcomes, the greatest possible connections among schools, parents, and implant programs should be forged. Indeed, it is likely that in some cases teachers may not be privy to much of the information that parents receive about the particular application of the implant in relation to their child. Teachers of the deaf may have a broad or even detailed understanding of cochlear implantation, but not the specifics related to any individual child, specifics which parents may be able to provide. In addition, the maintenance of the device necessitates strong communication links among teachers, parents and implant clinic professionals.
The effect on children’s outcomes and parents’ stress of living in regional and remote areas and thus at some distance away from easily accessible habilitation, early intervention and speech therapy services was clear in both the quantitative and qualitative findings. The current efforts of early intervention programs and educational authorities to expand their services to more distant geographical areas need to be continued and expanded.
Although parents and teachers reported better outcomes for those children who were not using sign, a substantial proportion of children were considered to need, and were using, Auslan or signed English, and many parents and teachers saw the use of sign as not incompatible with the main aim of the development of oral communication and cognition. However, parents’ knowledge about sign language was often limited and access to information and direct experience with Deaf people was difficult for those families who did not live in metropolitan areas. Indeed, the impact of bilingual programs in Australia is relatively idiosyncratic and not pervasive, and the connections between parents and bilingual programs would seem to be relatively ad hoc in our data, particularly in comparison to some European contexts. The way in which parents might become associated with a bilingual program is not actively promoted in state policies and systems, nor is it by implant programs. State education authorities should be encouraged to more comprehensively explain the purposes behind their bilingual programs and particularly how they relate to processes of implantation. Deaf associations and deaf adults need to be more actively involved in this debate. Parent organisations such as Aussie Deaf Kids might well play a vital, yet perhaps insufficiently recognised, role in the process of connecting parents with deaf organisations, deaf adults, and bilingual programs. In addition, organisations such as Deaf Children Australia that promote the full range of communication and educational options and offer non-biased information and non-judgemental support to families of deaf children clearly have a valuable role to play, particularly in the early stages of families’ decision making about cochlear implantation and the options, opportunities, supports and resources that are available. From our findings, organisations such as these would not seem to have been widely accessed by parents.
Both teachers’ and parents’ reports reflect limitations in the outcomes observed in relation to core elements (literacy and numeracy) of academic development. In addition, both groups of respondents reported delays or problems in aspects of social development. These two issues alone perhaps constitute the major challenge for schools, education authorities, and parents.

Forthcoming publications
This is to date one of the largest studies of its kind in the world on the outcomes of children with cochlear implants. In particular, research that directly compares parents’ pre-implant expectations with their later experiences of their children’s outcomes on a range of communication, psychosocial, and academic items with a large sample has not been reported in the literature. The current study involved a sufficiently large survey sample of parents and teachers to allow a robust procedure of statistical analysis, and the in-depth interviews with parents, teachers and young cochlear implant recipients themselves extended and elaborated on the quantitative survey findings. The study is able to make an important contribution to the literature and reveals that studies that examine variables beyond those of auditory functioning and speech and language development indeed have an important role in investigating the nature of implant programs and their follow-up, family supports, and educational processes.
If as stakeholders you are interested in or require particular sets of findings we would be able to accommodate this, but we would also expect that the detail in the forthcoming publications would cover most of these issues. Articles in preparation focus on the following specific areas:

· parents’ decision-making processes
· a comparison of parents’ expected and experienced outcomes of implantation for their children
· factors predicting children’s outcomes
· rehabilitation demands, stress, and the impact on families
· communication mode and the role of sign language in implanted children’s lives
· teachers’ perspectives of children’s outcomes and the educational supports received and needed
· social outcomes from the perspectives of parents, teachers, and the young people themselves.

Sincere appreciation is expressed to the Australian Research Council and to Deaf Children Australia for funding this project. Particular appreciation goes to Deaf Children Australia, the project’s partner organisation, without whose involvement the study would not have been conducted. We are grateful for the support and involvement of all the participating organisations and in particular all the parents, young people and teachers who gave freely of their time and shared their experiences for the conduct of this study.

Professor Merv Hyde AM PhD
School of Education and Professional Studies, Griffith University
[EMAIL="m.hyde@griffith.edu.au"]m.hyde@griffith.edu.au[/EMAIL]

Dr Renée Punch PhD
School of Education and Professional Studies, Griffith University
[EMAIL="r.punch@griffith.edu.au"]r.punch@griffith.edu.au[/EMAIL]

Appendix

Organisations participating in the research project

Australian Research Council
Deaf Children Australia
NSW Department of Education and Training
Queensland Department of Education, Training and the Arts
Victorian Department of Education and Early Childhood Development
Sydney Cochlear Implant Centre
Victorian Eye and Ear Hospital Cochlear Implant Clinic
Royal Children’s Hospital Cochlear Implant Clinic, Brisbane
Mater Cochlear Implant Clinic, Brisbane
Hear and Say Centre for Deaf Children
Royal Institute for Deaf and Blind Children
Taralye Oral Language Centre for Deaf Children
Parent Council for Deaf Education
Aussie Deaf Kids