The use of cochlear implants in children in the United States was first evaluated during the mid-1980s after Food and Drug Administration (FDA) approval of the House/3M single-channel device in adults. A substantial number of children received single-channel cochlear implants during an FDA-controlled multicenter study, beginning in 1983. Also in 1983, the first child received a multichannel device in Melbourne, Australia. Initiation of a pediatric clinical trial of the Nucleus multichannel cochlear implant occurred in 1986 after FDA approval for use of the device in adults in 1985. The clinical trials in children continued over a period of approximately 4 years, with 142 children receiving the device before FDA approval was granted in 1990.¹ Several upgrades of the Nucleus device, as well as several generations of the Advanced Bionics Clarion device, have undergone successful FDA trials; pediatric trials are currently ongoing with the Austrian-made Med-El. Results of these closely controlled studies indicate that cochlear implant manufacturers have made safety and efficacy claims for children that were supported by the trial data.

In addition to FDA trials, the National Institutes of Health (NIH) convened two consensus conferences on cochlear implants, one in 1988, and the second in 1995. In May 1995, nearly 200 professionals and interested parties gathered to assess the status of cochlear implants after 10 years of clinical use. As reflected by the consensus statement, the use of cochlear implants in children has been shown to “result in successful speech perception in children.” In addition, it was noted that “a younger age of implantation may limit the negative consequences of auditory deprivation and may allow more efficient acquisition of speech and language.”²

In spite of repeated FDA approval and NIH support for use of cochlear implants in children, a strong body of opposition to pediatric use of the device has remained. Few if any other proven treatment options for treatment of major pediatric health disorders have received the type and intensity of negative response which has accompanied use of the cochlear implant in children. As suggested by the title of this chapter, opposition has centered on resisting implantation of the congenitally deafened child. That adults and postlinguistically deafened children can benefit from implants has been acknowledged by most of those who continue to oppose its use in the congenitally deaf child. Primary opposition has come from members of the deaf world, a subset of the deaf community who hold more extreme views on the nature of deafness. They hold that deafness is not a disability, but is rather a natural human variation and therefore does not need to be treated medically.³ Support for their position has also been strong among some educators of the deaf and even among some medical and communication disorders professionals.

Initially, arguments against the cochlear implant were based on claims that congenitally deaf children do not derive benefit from cochlear implants. However, an increasing body of data supports that, given the appropriate circumstances, congenitally deaf children can indeed derive significant benefit from cochlear implants.^4–7 This has led to a revision of the argument to confirm that even though cochlear implants do work for congenitally deaf children, for other moral and ethical reasons, they should not be used in this population. Both concepts will be discussed in this chapter.

Congenitally Deaf Children Cannot Benefit from Implants

Initially, arguments against use of the implant in congenitally deaf children centered on the idea that individuals without prior exposure to speech and language could not make use of the information provided by the implant. Early in its development, the cochlear implant was seen primarily as an aid to speechreading, and there was little expectation that open-set speech recognition without visual cues was a realistic goal. Postlinguistically deafened adults with well-developed oral language were able to use a combination of speechreading and contextual information together with the auditory cues provided by the implant to improve communication abilities. Early results with prelinguistically deafened adults were not as promising, leading some researches to suggest that loss of hearing before speech and language acquisition was a significant deterrent to successful cochlear implant use, possibly due to lasting effects of auditory deprivation.¹

Studies such as those conducted by Shepherd et al.,⁸ Matsushima et al.,⁹ Lousteau,¹⁰ and Hartshorn et al.¹¹ have provided evidence that suggests otherwise. Animal studies have shown that even in the presence of the auditory deprivation caused by congenital deafness, some cochleotopic organization remains and that electrical stimulation may both prevent degenerative changes in the neural pathways and may in fact produce morphologic and physiologic changes that improve function. Obviously, the longer the period of deprivation, the greater the negative impact; the positive benefit of the implant decreases. This has implications when considering implantation of older congenitally deaf children and adolescents who have not been consistent users of amplification.

What at first appeared to be decreased ability to benefit from an implant has generally come to be recognized as a developmental issue. Instead of comparing the information provided by a cochlear implant to an existing store of auditory language as in the case of a postlinguistically deafened user, the congenitally deaf implant recipient must use the information to develop language, as would any infant. The normally hearing infant spends the first year of life listening and receiving language before beginning to use it expressively. Therefore, the time course of 1 to 2 years required to see substantial results with congenitally deaf implant users12 is developmentally appropriate.

Ethical Opposition to Cochlear Implants in Congenitally Deaf Children

Cochlear implants are one example in which technological advances have come into direct conflict with cultural values. Others include organ transplantation, gene manipulation, and artificial life-support systems. Cochlear implants, viewed as a medical achievement with the potential to alleviate the loss of a major sensory system by the medical community, represent confirmation to members of the deaf community that they are viewed as inferior and should be eliminated from the population. What appears as a solution to a problem by some is viewed as a “final solution” to a people and a way of life by others. Members and supporters of the deaf world consider those who communicate exclusively through American sign language (ASL) to represent an oppressed linguistic minority. They view attempts to provide hearing to deaf children as racist and genocidal.¹³ Opposition to cochlear implants from members of the deaf world does not arise out of concern that they do not work, but rather that they work well enough to allow the child to reject deaf culture in favor of mainstream society. We have written extensively on this conflict^14–17 and summarize those works in this discussion.

In order to understand why cochlear implant technology is perceived as a significant threat by the deaf community, it is important to note that 90% of deaf children are born to hearing parents and 97% have at least one hearing parent.³

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