Within this already controversial area, the rapid growth of cochlear implantation in children has added another dimension to the debate, and indeed evidence on outcomes after implantation and the influence of education is mixed, too. Parents, faced with yet another decision about the management of their deaf child, now routinely have another choice: that of implantation. Do they have the information on which to base these choices?

Deaf children were traditionally educated in schools for the deaf, often residential, and often in remote areas involving travel some distance from home. Large schools for the deaf were established in many countries in the 19th century, and children were taught according to the prevailing philosophies in those establishments. In the second half of the 20th century, increasing numbers of children with disabilities have been educated in mainstream schools with support, and teachers of the deaf led the way in promoting the movement toward mainstream placement of children with disabilities. Units, or special classes, were established in mainstream schools, staffed by teachers of the deaf, particularly in the United Kingdom, and since the 1970s more and more deaf children have been placed full-time in to mainstream schools with varying levels of support. For deaf children, the development of more effective hearing aids and the provision of frequency modulated (FM) systems have given them the possibility of greater use of audition to facilitate participation in mainstream education. The availability of cochlear implants is now moving this trend forward again.

There is a worldwide trend to educate all children with disabilities in the same mainstream class with their age peers, and increasingly in their local schools, with specialist support being provided in the class (Chute et al, 1996; Powers, 1996a). This movement responded to the growing awareness of the rights of those with disabilities, and the parallel demands by many minority groups for inclusion in the mainstream of society. For deaf children, it has led to the closure of some specialist schools for the deaf, which may be seen by the deaf community as a threat to their culture. Schools for the deaf have traditionally been centers where deaf culture and language have been transmitted, and where there has been a center of expertise in deaf education. With more children in mainstream, a reduction in special schools may mean greater difficulty in providing specialist support to deaf children, and greater difficulty in accessing those working with them in the mainstream for continuing professional development.

To summarize, the options for educational placement are as follows:

• A school for the deaf (residential or day)
  
• A unit or resource base in mainstream school (with varying degrees of integration)
  
• Mainstream school (with varying degrees of support in quality and quantity)

These situations are not mutually exclusive, but overlap to a large degree, with wide variations in practice, particularly in the degree of support. This makes comparisons about educational independence in varying educational settings complex, and hence comparing the effectiveness of different educational settings complex. Koch et al (1997) produced a useful matrix of educational resource use, illustrating the continuum of support; for example, a child in the mainstream with full-time support in class may in fact have less educational independence than a child in a class of 10 in a special school.

In addition to the debate about the relative value of different types of educational placement and levels of support, the debate as to which communication approach is most effective for deaf children continues. Traditionally there have been two extreme views: those of the oralists, who hold that all deaf children should communicate by spoken language alone, and those of the manualists, who hold that all deaf children should communicate by the language of the deaf, sign language. Although the oral view was held strongly in the 19th and the first half of the 20th centuries, it was challenged by reports of poor linguistic and educational attainments and speech intelligibility of deaf children, and by the increasing voice of the deaf community, wanting recognition of its own language and culture. In response, signed methods of communication were increasingly introduced to educational systems in many countries. This frequently took the form of total, or simultaneous, communication, where spoken language is used with signed support. In the 1980s there was the growth of interest in the use of sign bilingualism, using the language of the deaf community and the hearing community. However, as sign languages have their own grammar, it is not possible to use the two languages simultaneously, and transition to the written form of the hearing language (whatever it is) may be difficult. In the United States, the abbreviation “bi-bi” is often used, to denote bilingual and bicultural approaches.

Although terminology may vary, communication approaches may be grouped into three broad categories:

• Oral/aural alone
  
• Those using speech and sign simultaneously
  
• Bilingualism (Lynas, 1994)

The degree of dominance of one approach over another varies from country to country and from area to area in each country. For example, bilingualism is particularly strong in Scandinavia, where sign language has long been recognized as an official language. Within and across each category are subcategories, such as auditory verbal approaches, or structured oralism, complicating comparisons between categories. As with comparisons of the effectiveness of the different types of education placement that are available, the comparisons of the effectiveness of communication approaches on the attainments of deaf children are also inconclusive, for similar reasons (Powers et al, 1998). In the field of cochlear implantation, research into the comparative effectiveness of different modes of communication on progress after implantation has also often been inconclusive (Thoutenhoofd et al, 2005).

The Development of Pediatric Cochlear Implantation

Although there has been a global increase in the numbers of children receiving implants worldwide, the trend has not been consistent across countries, and there has not been equity of access to the new technology, regardless of the state of a country’s economy (O’Donoghue, 2004). Factors that have been observed to influence the availability of cochlear implantation for young children include the following:

• Development of child-appropriate technology
  
• Parental pressure
  
• Pressure from the deaf community
  
• Educational issues, including prevailing policies
  
• Evidence of outcomes
  
• Financial constraints
  
• Individual endeavors (Archbold, 2003)

Some of these factors moved implantation forward, whereas others delayed progress. It may be that “individual endeavors” is the strongest category of influence; for example, a country in Europe at the present time with one of the greatest incidences of childhood implantation is Croatia, largely due to the efforts of one particular individual. However, although pediatric implantation has moved ahead rapidly in terms of global numbers, it has not always been appreciated that the decision often made by parents on behalf of their child will have communication, language, and educational implications, and that the education system in which their child is placed is also likely to have an influence on outcomes from implantation.

The interaction between implantation and the education of the deaf has not yet been resolved: which influences the other? In efforts to utilize education as an outcome from implantation it may be that the influence of deaf education itself on implantation has not been sufficiently researched, nor have the most effective ways of educating the varied children who receive implants yet been identified. Ever more demanding groups of children are receiving implants, who require educational involvement in their long-term care:

• Very young deaf infants, following newborn hearing screening and earlier diagnosis
  
• Teenagers choosing implantation for themselves
  
• Children with very complex additional needs
  
• Those with more residual hearing, wearing a hearing aid and an implant
  
• Those with bilateral implants
  
• Deaf children of deaf parents

The research endeavors that have taken place into outcomes from cochlear implantation have identified influences such as age at implantation and duration of use, but have yet to identify more than 40 to 60% of the variance in outcomes for children with implants (Spencer and Marschark, 2003). It may be that some of the reasons for some of this variance lie in this difficult to assess area of educational management.

♦ Cochlear Implantation and Deaf Education

Surveys of implant professionals (Archbold & Robinson, 1997) and parents of children with implants (Archbold et al, 2002a; Hasenstab et al, 1997; Sorkin & Zwolan, 2004) found concerns about the education of children after implantation. In the questionnaire survey of parents by Sorkin and Zwolan, 30% of parents had experienced difficulty in obtaining the educational services they felt their child needed, and went on to describe the need for training about implantation, and for cochlear implant staff to be involved. In the qualitative study by Archbold et al, the links between the cochlear implant center and the local educational services was one of the major issues to arise spontaneously from parents. It is clear that cochlear implantation has brought together the medical and educational worlds in ways not previously envisaged, and requires professionals from different backgrounds to work together more closely than before. Educators, medical professionals, and audiologists may have different priorities following implantation: for the audiologist and the medical professional, the safety of the procedure and the changing of hearing thresholds may be the major goal, whereas for a teacher, the development of language, of literacy skills may be more important (Thoutenhoofd et al, 2005). The involvement of the child’s local educator in the implantation process may pose difficulties for a clinic-based implant team, organized on a medical model (Nevins and Chute, 1996); the child’s local educator may not be involved in the decision to implant or in the process itself, but may be left with the responsibilities for the long-term management of the child (Geers and Moog, 1995) and of the outcomes from implantation. It would not be surprising if many teachers felt under threat by the development of implantation, and uncertain of their role in the care of these children. It does seem clear that parents want a strong working link between the implant center and the educational system, wherever their child is educated; how this is managed is crucial to the sustained long-term management of children with implants.

Earlier, mention was made of the importance parents place on the liaison between the implant center and educational services (Archbold et al, 2002a) and of the finding of Sorkin and Zwolan (2004) that a significant proportion of parents felt that their child had inappropriate or no support. Hasenstab et al (1997) found that 30% of parents paid for additional services. The authors summarized the situation by quoting one parent: “If I had one wish for all implanted kids and their families, it would be to have excellent services locally. Services are usually available and even funded but too often woefully poor or inappropriate.” It seems that the situation had not improved in the United States in the intervening 7 years, and are unlikely to have improved elsewhere. In those 7 years there had been a great deal of work on rehabilitation materials for children with implants from a variety of sources, and many implant centers provided rehabilitation services. Why does the situation seem not to have improved?

♦ Conflicts Between Cochlear Implant Centers and Educational Services

Public services worldwide are under tremendous pressure to provide and improve their services as measured against specified targets. For implant centers, in medical contexts, and teachers, in educational services, these pressures may produce further tensions in meeting different goals. For teachers, providing educational services in societies with changing expectations and demands, the advent of cochlear implantation has brought fresh challenges and responsibilities. Although there is evidence on the efficacy of implantation in terms of improved auditory perception and hence speech perception and production (Thoutenhoofd et al, 2005), there remains wide variation in outcome, and the delays in deaf children’s language continue to be a challenge for educators (Spencer & Marschark, 2003).

Although cochlear implant centers continue to be based in medical environments, and teachers and classroom support are provided in educational institutions, there remain several potential conflicts; how they are resolved is vital for the secure future of current child implant users. For educators, the perceived conflicts are as follows:

• Inequity in the time and money it takes to teach children with and children without implants
  
• Inconsistency of input, expectations, and goals among implant centers, parents, and educational services
  
• Pressure on educator’s time to acquire new and changing knowledge
  
• Responsibility for the day-to-day management of rapidly changing, complex technology
  
• Pressure on educators’ financial budgets for training, spare parts for the implant systems to be used in school
  
• Demands on educators to be responsible for ongoing support for children with implants, often without advice or support from an implant center
  
• Pressure on educators to be responsible for outcomes from implantation for implant teams, which may not be the priority of the educator
  
• Managing the changing needs of children following implantation: changes in placement and in communication mode, requiring flexibility of management
  
• Confusion over roles and responsibilities

With growing numbers of children receiving cochlear implants, it is timely to look anew at the ways of managing them; their needs may not be so very different from those of hearing aid users, and they should be brought into the mainstream of deaf education, which may not necessarily be mainstream education itself! What are their educational needs? In common with other deaf children, they require the following opportunities:

• To acquire communication and language skills
  
• To develop their cognitive potential
  
• To access a curriculum appropriate for their stage of development
  
• To develop their personal self-esteem and to develop age-appropriate social skills

To utilize the implant system fully in these educational goals, they also require the following:

• An optimally working implant system at all times
  
• Good acoustic conditions to promote the development of listening within the learning environment
  
• High expectations of high-frequency speech information

For children with implants, the use of the implant system to its optimum is dependent on the combined skills and expertise of the implant center and educators responsible for the child. The implant center is likely to retain the specialist knowledge about implant systems and their management, and the educators are likely to know the child and the learning situation best. How can this responsibility be shared?

With adult implantation, models of rehabilitation after implantation were developed that were largely clinic-based, which was essential for adults who were unlikely to have other sources of support. With the advent of childhood implantation, these models continued, with clinic-based rehabilitation after implantation being common. However, as the need to provide long-term care for children with implants became apparent, several service models developed to address these issues (Chute et al, 1996; Cowan, 1997; Robbins, 2000). Cowan identified three forms of pediatric rehabilitation:

• Solely in implant clinics
  
• Specialized educational settings or schools, incorporating or liaising with an implant center
  
• Outreach programs from implant centers

These models have been described over the years: Bertram (1996) and Sillon et al (1996) described two clinic-based rehabilitation services, and an innovative model of service delivery has been discussed by Muller et al (1996), who describe the development of a complete implant support system. This established cooperation between school and clinic, with shared personnel and facilities. Nevins (1991) and Archbold (2003) describe the educational liaison model in which educational consultants from the implant center visit the child’s own educational setting to liaise with educators directly, the aims being:

• To provide direct contact between implant center and home and school
  
• To ensure that the implant system is managed appropriately at all times
  
• To ensure that ongoing support is appropriate
  
• To provide training for teachers of the deaf in cochlear implantation
  
• To monitor the child’s progress in real-life settings

Working with the local educators may well be the most time-and cost-effective way of working in the long term (Chute et al, 1996). Passing on the skills to those in daily contact with the child may serve several purposes:

• Supporting the use of the implant in appropriate children
  
• Extending the skills of the local educators in the management of children with implants
  
• Anticipating and smoothing out possible areas of conflict between the implant center and the educators, ensuring consistency of care
  
• Promoting cooperation between implant clinic and educators

In the United States, the international group Network of Educators of Children with Cochlear Implants (NECCI) (Nevins and Chute, 1996) has long been established and continues to work with educators supporting children with implants, and in the United Kingdom, the teachers of the deaf employed by implant teams meet as a group, ICTOD (Implant Center Teachers of the Deaf), to ensure consistency of practice. They have developed guidelines for good practice, published by Royal National Institute for the Deaf (RNID) (2003). Educational liaison is seen as essential, but must be based on ongoing professional development. Cochlear implant centers and companies provide a great deal of training for the many professionals working with children with cochlear implants; are we sure that we are reaching those who manage the child in the classroom on a daily basis? With more children in mainstream it is more difficult to target those supporting individual children, who may not be a teacher of the deaf, and who may be difficult to reach for training. In the United Kingdom, the Ear Foundation provides ongoing training for a range of professionals, but particularly for teachers working with deaf children with implants on a daily basis. These courses cover up-to-date criteria and processes, and the management of a range of deaf children, from those implanted as infants, to the different needs of teenagers. One of the greatest demands is for training for classroom assistants who provide individual support for deaf children in mainstream classes but who may have no training. The aim of such continuing professional development is to provide an informed infrastructure for the children wherever they live, and to ensure that they have local technical support and appropriate expectations wherever they attend school; 20% of delegates attending the courses do so from outside the United Kingdom, indicating a demand for such training. Educational services are changing in response to the demands of cochlear implantation, but there is little evidence that they are changing as a whole sufficiently to develop the potential we now know is possible for children with implants, in light of the lengthier experience we now have. Conferences of groups of teachers of the deaf around the world often do not feature the needs of those with implants, who now form a significant group of profoundly deaf children. Do teachers of the deaf know what the educational implications of cochlear implantation are for the children in their care?

♦ Educational Outcomes from Cochlear Implantation

First, educational placement has been of particular interest in considering the outcome of pediatric cochlear implantation, as it has been used in studies of cost-benefit (Cowan, 1997; Francis et al, 1999; O’Neill, 2000; Schulze-Gattermann et al, 2002; Summerfield et al, 1997). It must be recognized from the outset that placement decisions may be influenced by political influences and availability as much as by the assessed needs of the child; this is true within and across countries. However, the current evidence shows that significantly more children with cochlear implants tend to go to mainstream schools than those with hearing aids. Both Chute and Nevins (1994) and Archbold et al (1998) showed a trend to mainstream provision; Archbold et al found that age at implantation and duration of deafness were significant predictors of educational placement. Archbold et al (2002) compared aged-matched groups (5 to 7 years of age) in the United Kingdom with and without implants; all those implanted were implanted before the age of 5. They found that significantly more of the profoundly deaf with implants were attending mainstream schools and significantly fewer schools for the deaf. However, the conclusions still remain tentative: these were young children, and secondary or high school education remains a challenge. It is necessary to follow up these results as more children, receiving implants as young children, enter secondary education and we have the numbers to carry out such studies. However, Fortnum et al (2002) reached a similar conclusion in a UK study of 757 children with cochlear implants. Another large, US-based study reported by Geers and Brenner (2003) found that children tended to move from private and special school settings to mainstream provision after implantation; the evaluations were performed 4 to 7 years after implantation on children who were implanted before the age of 5. Daya et al (2000) also report a trend to mainstream placement.

However, the real educational outcomes are those of educational attainment; Powers (1996b) suggested that investigating educational outcomes is crucial in any discussion of the value of educational placement. Some reports claim that the educational attainments of those deaf children in mainstream schools are higher than those in special schools for the deaf. Such conclusions are confounded by the “chicken and egg” factor: it may be that those placed in mainstream schools have greater potential than those placed in special schools, and this was the very valid reason for the placement decision. Claims that mainstreamed children attain higher educational attainments than those in special schools may not take into account all the factors.

Although it is hoped that increased spoken language abilities will improve the literacy levels of profoundly deaf children, little work has been undertaken to look at attainments following implantation (Spencer and Marschark, 2003; Thoutenhoofd et al, 2005). A major UK study undertaken by Summerfield (2004) and Fortnum et al (2002) also looked at attainments of the children with cochlear implants and those with hearing aids. When educational attainment was estimated by teachers as a composite of abilities in reading, writing, and arithmetic, and compared with hearing loss, as hearing loss increases, attainments decrease for those with hearing aids, but is roughly constant for children with implants—for those with hearing losses over 100 dB. The children in this study were those implanted later than the current candidates and were implanted with earlier devices than those currently used; it may well be that these outcomes prove conservative in the long run.

Geers (2003) also reported on outcomes in reading skill development, an area where deaf children have a long history of very delayed development. Although finding a wide variation, Geers found in a group of 181 8-and 9-year-olds that early implantation was associated with a more normal rate of reading development. Spencer et al (1997) also reported improved reading scores for children with implants, but Wauters et al (2002) found no difference in reading skills in those who had implants. Clearly there have not yet been enough children with long-term usage of up-to-date devices to make reliable conclusions; however, the growing evidence is that early implantation in particular is linked with improved linguistic outcomes and hence educational attainments, such as reading.

In addition to looking at educational attainments of children with implants, we need to consider the psychosocial perspective of placing a deaf child in a mainstream school. Children remain deaf after implantation, and even a mild, unilateral loss can affect a child’s classroom performance (Most, 2004). Chute et al (2004) also reported children with implants having difficulties in areas of classroom management and behaviors, when compared with their hearing peers. Many consider that education solely with hearing children deprives them of their need for a peer group and to learn about issues of deaf culture. There is a need to ensure that educational placement decisions are made with regard to the needs of the child, rather than political issues. The checklist devised by Chute and Nevins (1996), and the Screening Instrument for Targeting Educational Risks (SIFTER), devised by Anderson (1989) are useful in ensuring that these decisions be made with an element of objectivity by classroom observation rather than for political or economic reasons.

Whatever the complexities of the issue of educational placement for children following implantation, there does seem to be some early evidence that children who receive implants when young tend to go to mainstream schools, compared with conventionally hearing-aided children, and fewer to schools for the deaf, with implications for the organizations of educational services. What of the evidence of the influence of cochlear implantation on the decisions with regard to the communication mode used with profoundly deaf children? Again, we are faced with the question of which comes first, the choice of communication mode, or the evidence of its effectiveness. The evidence is mixed, but where there is a difference it is in favor of oral settings.

In early studies, McConkey Robbins (McConkey Robbins et al, 1997) and Connor et al (2000) showed little or no difference in outcomes from those in oral or total communication settings. Tait et al (2000) reported that it was the quality of the early communication of children and caregivers, rather than modality, that influenced progress after implantation. In a study looking at language progress, Svirsky et al (2000) found no difference in language levels between those in total communication and those in oral settings. When they looked at only spoken language, there was a difference in favor of those in oral settings; this illustrates the importance of being clear about the use of terminology in these research studies. In tests of speech perception and production it is highly likely that those in oral settings will outperform those in total communication or signed settings; for educational purposes, we must look carefully at language outcomes.

Osberger et al (1998) observed children in oral settings significantly outperforming those in total communication settings. Miyamoto et al (1999) also found significant effects of oral communication mode in tests of speech perception and production. In more recent work, Geers et al (2003) found oral communication strongly linked with speech perception skills and language skills. In the same study, Tobey et al (2003) found oral communication also linked with speech production skills.

Archbold et al (2000) investigated children in oral settings and those using signed approaches, finding that, 3 years after implantation, those in oral settings outperformed those in signed settings on measures of speech perception and production. However, when those who had always been oral communicators were compared with those who had used sign and changed to oral communication 3 years after implantation, there was no significant difference between the two groups. In a further study of 176 children, 5 years after implantation, (Watson et al, 2006), the changes in groups of children after implantation were studied. Changes in communication mode were significantly related to age at implant; in children implanted before the age of 3, 90% were using signing prior to implant, and 5 years after, 83% of the same group were using oral communication. For children implanted young, changes tended to take place in the first 2 years of implant use, and to take place later and over a longer period of time for older implanted children. Clearly it is possible for children to change communication mode after implantation, and it is essential that educational services recognize this and provide services that monitor and facilitate such changes. Those children who had little audition prior to implantation, and therefore used sign communication, may well, as they grow used to improved access to speech via audition through the implant, become able to use spoken language as their main means of communication, of acquisition of language, and of access to the curriculum. They will need an education system that can provide communication choice and can facilitate the change.

Based on recent reports, it would appear that the majority of children implanted young are developing the ability to use spoken language as their main means of communication and hence for education. What is difficult to determine is to what extent the cochlear implant influences the outcome and to what extent the outcome from cochlear implantation is dependent on the educational support of the child. Research into outcomes from cochlear implantation in young children has only served to confirm what deaf researchers have always known: the relative influences of the many variables are difficult to identify (Wood et al, 1986).

We asked whether cochlear implantation was influencing educational practice, or vice versa. On reviewing the evidence available, the answer would appear to be that each is influencing the other: educational policies and practice may well have influenced the varying levels of practice of implantation in different countries and influenced outcomes, and implantation itself would appear to be influencing decisions of placement, communication mode, and educational attainments themselves. The practices of education and implantation seem to be inextricably linked. How can we move educational services forward so that children with implants receive the best possible long-term care?

♦ The Future of Deaf Education for Children with Cochlear Implants: Addressing the Differences

With the current numbers of children with implants and the continued expansion of implantation in countries where it is well established, most teachers of the deaf will be required to teach a child with an implant at some time in their careers. Implant teams’ emphasis on the specialist rehabilitation of children after implantation may have deskilled teachers of the deaf. Has unnecessary mystique built up to support an industry of rehabilitation for children with implants? Are there differences between a child with useful hearing with a hearing aid and one wearing an implant? The major differences that are emerging more clearly are as follows:

• The access to high-frequency hearing is rare in a hearing aid user.
  
• The complexity of monitoring device functioning
  
• The complexity of device programming
  
• The implementation of changes in technology over time
  
• The management of device and technology difficulties
  
• The length of time taken for progress—often years not months
  
• The flexibility of educational support required: placement, levels of support, and communication may change over time
  
• The medical risks associated with implantation

1. It may be that implants often work too well. The speech intelligibility of some children may appear normal and such that there appears to be no difficulties for the child, whereas if we explore the child’s functioning in everyday life, rather than in the clinic, we may notice the more subtle difficulties experienced by someone with a moderate, rather than a profound, hearing loss. Then the expertise of the teacher of the deaf will be required in subtle ways to monitor and facilitate progress to ensure that the child’s linguistic and educational potentials are achieved.
   
2. There are other children who do not do as well as one might have predicted; a recurring theme in the literature is the variability of outcomes. It is likely that these children have difficulties not identifiable prior to implantation. Once the child has some useful hearing, it may become apparent that the child has a language difficulty, for example, and the major difficulty may no longer be deafness. Cochlear implantation is enabling teachers of the deaf to identify these children for the first time, but we may not know how best to educate them.
   
3. Another recurring theme in discussions about implantation is the management of those with implants as they grow through adolescence, and maintaining and developing implant use through these challenging times (Beadle, 2004). At this time, implant system malfunctions may appear after several years, and require sensitive handling with the implications that changes in hearing levels may have at a time of demanding education. During adolescence, there are reports of changes in levels and occasional sensations of pain. Again, these need sensitive educational responses to ensure that the necessary changes are made. A child may reach adolescence and question the value of the implant system, as many do with hearing aids, and question the decision made by parents. An adolescent who received an implant early and uses spoken language well, may wish to talk more fully about deaf issues. The issues of adolescent management are unlikely to be best met by implant center staff or by parents; educators may be in the best position to handle these situations, but not in isolation.

For experienced teachers of the deaf, cochlear implantation should not bring major challenges, if there is a commitment to the use of audition in the child’s development of communication and language and a link with the child’s implanting center. Educational services often provide these services over the years for those with hearing aids; they should be able to do so for those with implants. However, they will require close liaison with the implanting team, and to be enabled to take on these roles. Implant teams need to recognize the local educators as partners, so that, in the long term, the day-to-day responsibilities for managing the implant system and promoting its use on an everyday basis are shifted to the local teacher.

In order for teachers to become experts in the ways in which cochlear implants can offer new opportunities for the children in their care, initial and ongoing training is required. In both the United States and the United Kingdom, there are active training opportunities for teachers to acquire the necessary knowledge and skills. Teachers need to know about the following:

• The differences between cochlear implants and hearing aids
  
• Appropriate candidature
  
• Expectations from implantation for different populations
  
• The fundamentals of an implant system
  
• The basics of the tuning process
  
• Monitoring the system functioning and troubleshooting it
  
• Monitoring the child’s progress

These are some of the everyday knowledge and skills required; however, for them to be put in place and utilized effectively, there may need to be some organizational changes, for both educational services and implant centers. Educational services need to look at the following:

• How they organize their services to provide effective, trained support in the classroom for those in mainstream
  
• How they provide placement and communication choices as children’s needs change
  
• How they provide appropriate education for those for whom an additional language difficulty may become apparent after implantation
  
• How they provide support for the implant system in the demanding environment of secondary or high school
  
• How they implement changes in technology and support them throughout the child’s educational life
  
• How they provide for the psychosocial needs of the children as the children grow to independence

This cannot be done without the expertise of the implant center team and without ongoing professional training— given in the right place and in accessible ways. Increased liaison between implant teams and the child’s own educator should ensure consistency of care, optimize the teacher’s knowledge about implantation, and be cost effective in the long term. The potential conflicts of discrepancy between rehabilitation implemented by an implant team and the educational goals and the disruption to education by possibly unnecessary visits to an implant center can be minimized and the child’s ongoing care ensured by the implementation of an informed infrastructure. As teachers of the deaf become more familiar with the technology and expected range of outcomes, they would be able to be more effective in the assessment period, helping to ensure that appropriate children receive implants, and that all concerned have realistic expectations. Training educators and linking implant center and educational service can take place utilizing the new technologies, providing monitoring, support, and training via video links, and Webcams, ensuring it is available for all.

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