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Rehabilitation
pre- and post-

Cochlear Implant
era
Dr. Dr. h.c. Monika Lehnhardt
Founder of Lehnhardt Academy and
Chairwoman of Prof. Ernst Lehnhardt-Foundation




Yerevan - November 23rd 2010
A look into the history of deafness
  •Before   the 1970s, deafness was considered to be an irrevocable blow of fate.

Congenital deafness resulted in muteness and educational support
  relied on visual perception and feeling of vibrations. It was rather an
  exception that a deaf born infant would learn to listen and talk.
The reason for deafness was seen to be retro-cochlear, which we know
  is not the case in 95 percent of the deaf population.
Parents felt guilty or ashamed to have a deaf child and would try to hide
  it away.




 www.monika-
 lehnhardt.net
A look into the history of deafness
                    •Quotes   of famous people




                          Aristoteles
                •   Aristoteles: deaf people are not subject to any
                    education
                •   Paulus: Ex auditu fidem (Belief is based on
                    hearing)
                •   St. Augustine: hearing impairment is a
                    deficiency which impedes belief
                •   Leonardo: deaf people as “an object for visual
                    perception”
www.monika-
lehnhardt.net
A look into the history of deafness
                              •Famous    deaf people


Famous people suffering from deafness included artist Francisco de
  Goya, composer Ludwig van Beethoven and Czech composer
  Bedrich Smetana. They all suffered from their condition, which was
  reflected in their art.




          Beethoven’s music became much darker as his hearing loss progressed

www.monika-
lehnhardt.net
A look into the history of deafness
                 •Sign   language


                           Sign language was invented
                             by ‘silent’ monk
                             communities and has
                             been in use since the 16th
                             century.
                           Controversies over sign
                             language include
                             disputes over whether it
                             is a real language or not.
                             Diderot and Rousseau
                             conclude that it is.
www.monika-
lehnhardt.net
A look into the history of deafness
                •Francisco   de Goya’s ‘Ydioma Universal’



                                     In 1797, five years after he lost
                                        his hearing, Goya published
                                        the “Ydioma universal” – a
                                        sign language for the deaf,
                                        which is in the Museo del
                                        Prado in Madrid now and
                                        another 5 years later, in 1812,
                                        he completed a drawing
                                        showing the alphabet for the
                                        deaf-mute.



www.monika-
lehnhardt.net
A look into the history of deafness
•Oralism   - a concept whereby people with hearing impairments should be educated using
                                  spoken language only

                                         Abbé de l’Epée (1712 – 1789) was the
                                            founder of the first school for the
                                            deaf in 1770 in France.
                                         In America Thomas Gaullaudet
                                            founded the first school for the deaf
                                            in the year 1816.
                                         In 1970 finger alphabet was
                                            reintroduced for classes in deaf
                                            schools in Germany. Sign language
                                            was banned in France until 1976
                                            and in Austria the ban was lifted
                                            only in 1984.


    www.monika-
    lehnhardt.net
A look into the history of deafness
          •Hearing   movements in the 19th and 20th centuries

•   Itard (1774 – 1838), Urbantschitsch (1847 – 1921),
    Bezold (1842 – 1908) and Kroiss (1861 – 1945) tried to
    find out how to develop hearing despite a severe
    hearing impairment. Results were disappointing as the
    technical quality of hearing aid instruments was poor.
•   1930-1960: the emphasis was on vision, lip reading
    and vibration.
•   1960-1985: understanding the importance of early
    detection and intervention. Armin Löwe introduced a
    programme for early support and intervention in
    Heidelberg in 1959.
•   In the late 80s a new era began.

www.monika-
lehnhardt.net
The landscape of deafness has changed
•New   technology caused a shift of paradigm in the methodology of rehabilitation

                                  •   We started to understand how the
                                      development of hearing and speech
                                      happens and learnt that we are not
                                      hearing with our ears but with the
                                      possibilities of the brain’s central
                                      nervous system.
                                  •   Reliable test equipment became
                                      available, the quality of audiometers
                                      and other instruments improved
                                      significantly. Intervention started at a
                                      very early age.
                                  •   Deafness is no longer considered an
                                      irrevocable blow of fate but a neuro-
                                      developmental emergency.

www.monika-
lehnhardt.net
Rehabilitation of children with Cochlear
                Implants
                         a new era in the rehabilitation for
                         CI recipients has just begun and
                            web-based learning, teaching,
                                   fitting and rehabilitation
                                  will significantly improve
                           the overall quality of outcomes
                                              for CI wearers




www.monika-
lehnhardt.net
Rehabilitation
      •Methodologies   currently applied working with children with CIs

                            •   Sign language
                            •   Cued speech
                            •   Total communication
                            •   Simultaneous communication
                            •   Guberina method
                            •   Natural Aural approach
                            •   Auditory verbal therapy




www.monika-
lehnhardt.net
Rehabilitation
Regardless of which methodology is applied – the most
  convincing argument is the success of the therapy:
  establishing hearing as an integral part of the child’s life,
  developing her/his communicative and verbal skills and
  improving them continuously over the years”.




 www.monika-
 lehnhardt.net
Rehabilitation
         •Organization   of rehabilitation for pediatric CI recipients
                     •     Fitting of the speech processor (5
                           weeks post-operatively, during 3 –
                           5 days, preferably in a CI Centre)
                     •     Therapy should comprise on
                           average 12 days per year until the
                           recipient reaches the age of 20.




www.monika-
lehnhardt.net
Rehabilitation
            •Answers   to selected country-specific questions


                          From the range of issues related to
                             rehabilitation of children with CIs,
                             we selected seven important
                             questions and searched the data
                             in various European states for
                             answers.
                          We have uncovered very
                             heterogeneous evidence!




www.monika-
lehnhardt.net
Selected answers
                •Q1.   Where does rehabilitation happen?
                       •   In Germany and Austria: inside the hospital
                           or outside
                       •   Switzerland: in educational facilities
                       •   Spain: in schools
                       •   Portugal: two clinics offer rehabilitation in
                           house (Coimbra and Estefania), all other is
                           happening outside
                       •   UK: in and outside the hospital, in health
                           care as well as in educational facilities. There
                           are no special Cochlear Implant
                           Rehabilitation Centres
                       •   Central and Eastern Europe: schools for
                           the deaf
                       •   Czech Republic: clinic, schools, local
                           facilities
                       •   Lithuania: educational institutions

www.monika-
lehnhardt.net
Selected answers
                •Q1.   Where does rehabilitation happen?
                        •   Poland: in clinics, healthcare facilities,
                            Polish Association for the Deaf
                        •   Latvia: specialized healthcare facility
                        •   Bulgaria: hospitals, schools and also a
                            special Centre for rehabilitation of CI
                            recipients
                        •   Romania: in state-owned special
                            schools for deaf children or in private
                            individual speech therapy offices
                        •   Croatia: special centres for hearing
                            impaired children or for children with
                            additional impairments
                        •   Serbia: in some centers
www.monika-
lehnhardt.net
Selected answers
•Q   2. Is the surgeon globally responsible for the CI recipient or only for surgery

                                     The surgeon should take the overall
                                        responsibility!
                                     This is recognized in most countries
                                        (Germany, Switzerland, Poland
                                        etc.)
                                     In Central and Eastern Europe the
                                        surgeon is only responsible for
                                        the operation




www.monika-
lehnhardt.net
Selected answers
•Q   3. Is each professional responsible for his own activity only or is there one person with
                             a global responsibility and who is it?

     Every professional is responsible for their work. Ideally, the head of
        the implanting clinic/coordinator takes overall responsibility.
     In Germany this is the case in clinics with a very high number of
        annual implantations.
     UK: a “key worker” to coordinate
        all activities, each professional
        is still responsible for their work.
     Poland, Latvia: one person
        with overall responsibility.
     Other CEE states: with a few
        exceptions this is not the case.
     Varese, Italy: trans-disciplinary
        approach.

      www.monika-
      lehnhardt.net
Selected answers
  •   Q 4. Is rehabilitation a health care activity or an educational activity?
                                         •   Germany: a health care
                                             activity and paid for by the
                                             health insurance companies
                                             (Krankenkassen).
                                         •   UK: a health care activity in
                                             the early phase and as an
                                             educational activity long-
                                             term.
                                         •   Poland, Latvia, Bulgaria
                                             and Croatia: a health care
                                             activity because it is paid for
                                             by the Ministry of Health.
                                         •   Czech Republic and
                                             Serbia: both.
                                         •   Lithuania: an educational
                                             activity.
www.monika-
lehnhardt.net
Selected answers
   •   Q 4. Is rehabilitation a health care activity or an educational activity?
I believe that rehabilitation of paediatric CI recipients and counselling of
    parents is an educational activity, regardless of where it happens. Only
    a few components like first fitting and regular adjusting of the speech
    processor programmes and obviously regular medical follow-up do not
    belong to the educational process.




www.monika-
lehnhardt.net
Selected answers
•   Q 5. What about the educational background / degree of the specialist in
                   rehabilitation for the deaf CI recipient?
                                       •   Pedagogues for hearing
                                           impaired, logopeds, audio
                                           therapists, psychologists, ergo
                                           therapists, teachers, social
                                           pedagogues, music therapists,
                                           paedaudiologists etc.
                                       •   Germany, Austria and
                                           Switzerland: no legal
                                           requirement for a special
                                           degree but most professionals
                                           have one in the field of special
                                           pedagogy. 90% are female.
                                       •   The situation is practically the
                                           same in the UK, Spain and
                                           other Western as well as CEE
                                           countries.

www.monika-
lehnhardt.net
Selected answers
•    Q 6. Who does the rehabilitation of deaf people? Hearing specialists or experts in
                  communication from a more general point of view?

                                     Pedagogues who have the
                                       competence of sign
                                       language work in the
                                       rehabilitation for deaf people.
                                       We could call these experts
                                       in communication.
                                     For CI recipients it is in all
                                       countries specialists for
                                       hearing (but not necessarily
                                       medical doctors).
    www.monika-
    lehnhardt.net
Selected answers
•   Q 7. Are there centres dedicated exclusively to deaf care in your country? Are there
                     special centres for rehabilitation for CI recipients?

    •   Germany: Schools for the Deaf  schools for hard
        of hearing; special Rehabilitation Centres for CI
        recipients; special institutions for early support and
        intervention (Frühförderung), special boarding
        schools and vocational training establishments
    •   UK: special Cochlear Implant Rehabilitation Centres
        do not exist. Rehabilitation is provided in different
        places to support the development of spoken
        language and this is for children with hearing aids as
        well as for CI recipients.
    •   CEE: special CI rehabilitation centres are an
        exception.

    www.monika-
    lehnhardt.net
Landscape of global communication changed
       •   Web-based Learning, Teaching, Fitting and Rehabilitation


                            The Internet
                               •   a revolution in global
                                   information
                               •   geographical boundaries
                                   overcome
                               •   social impact: social
                                   networks, forums and
                                   environments
                               •   new possibilities for
                                   hearing rehabilitation
 www.monika-
 lehnhardt.net
Landscape of global communication changed
          •   Web-based Learning, Teaching, Fitting and Rehabilitation

 •   LiveOnline Room: every participant (wherever she/he is) can become active
     at the same time by writing into the text chat and it becomes visible to all
     participants who are logged in including the presenter.
 •   Three communication modes are possible simultaneously: listen and talk
     read and write, see and present.




 www.monika-
 lehnhardt.net
Landscape of global communication changed
•    Advantages of post-operative care for CI recipients in a web-based environment



                                           •   Independence of
                                               distance
                                           •   Cost and time savings
                                           •   Higher chance for
                                               increased frequency of
                                               “meetings”
                                           •   Remote fitting



    www.monika-
    lehnhardt.net
Please contact us




www.monika-
lehnhardt.net
Thank you for your attention!




www.monika-
lehnhardt.net

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Rehabilitation pre- and post-Cochlear implant era - Dr. Dr. h. c. Monika Lehnhardt

  • 1. Rehabilitation pre- and post- Cochlear Implant era Dr. Dr. h.c. Monika Lehnhardt Founder of Lehnhardt Academy and Chairwoman of Prof. Ernst Lehnhardt-Foundation Yerevan - November 23rd 2010
  • 2. A look into the history of deafness •Before the 1970s, deafness was considered to be an irrevocable blow of fate. Congenital deafness resulted in muteness and educational support relied on visual perception and feeling of vibrations. It was rather an exception that a deaf born infant would learn to listen and talk. The reason for deafness was seen to be retro-cochlear, which we know is not the case in 95 percent of the deaf population. Parents felt guilty or ashamed to have a deaf child and would try to hide it away. www.monika- lehnhardt.net
  • 3. A look into the history of deafness •Quotes of famous people Aristoteles • Aristoteles: deaf people are not subject to any education • Paulus: Ex auditu fidem (Belief is based on hearing) • St. Augustine: hearing impairment is a deficiency which impedes belief • Leonardo: deaf people as “an object for visual perception” www.monika- lehnhardt.net
  • 4. A look into the history of deafness •Famous deaf people Famous people suffering from deafness included artist Francisco de Goya, composer Ludwig van Beethoven and Czech composer Bedrich Smetana. They all suffered from their condition, which was reflected in their art. Beethoven’s music became much darker as his hearing loss progressed www.monika- lehnhardt.net
  • 5. A look into the history of deafness •Sign language Sign language was invented by ‘silent’ monk communities and has been in use since the 16th century. Controversies over sign language include disputes over whether it is a real language or not. Diderot and Rousseau conclude that it is. www.monika- lehnhardt.net
  • 6. A look into the history of deafness •Francisco de Goya’s ‘Ydioma Universal’ In 1797, five years after he lost his hearing, Goya published the “Ydioma universal” – a sign language for the deaf, which is in the Museo del Prado in Madrid now and another 5 years later, in 1812, he completed a drawing showing the alphabet for the deaf-mute. www.monika- lehnhardt.net
  • 7. A look into the history of deafness •Oralism - a concept whereby people with hearing impairments should be educated using spoken language only Abbé de l’Epée (1712 – 1789) was the founder of the first school for the deaf in 1770 in France. In America Thomas Gaullaudet founded the first school for the deaf in the year 1816. In 1970 finger alphabet was reintroduced for classes in deaf schools in Germany. Sign language was banned in France until 1976 and in Austria the ban was lifted only in 1984. www.monika- lehnhardt.net
  • 8. A look into the history of deafness •Hearing movements in the 19th and 20th centuries • Itard (1774 – 1838), Urbantschitsch (1847 – 1921), Bezold (1842 – 1908) and Kroiss (1861 – 1945) tried to find out how to develop hearing despite a severe hearing impairment. Results were disappointing as the technical quality of hearing aid instruments was poor. • 1930-1960: the emphasis was on vision, lip reading and vibration. • 1960-1985: understanding the importance of early detection and intervention. Armin Löwe introduced a programme for early support and intervention in Heidelberg in 1959. • In the late 80s a new era began. www.monika- lehnhardt.net
  • 9. The landscape of deafness has changed •New technology caused a shift of paradigm in the methodology of rehabilitation • We started to understand how the development of hearing and speech happens and learnt that we are not hearing with our ears but with the possibilities of the brain’s central nervous system. • Reliable test equipment became available, the quality of audiometers and other instruments improved significantly. Intervention started at a very early age. • Deafness is no longer considered an irrevocable blow of fate but a neuro- developmental emergency. www.monika- lehnhardt.net
  • 10. Rehabilitation of children with Cochlear Implants a new era in the rehabilitation for CI recipients has just begun and web-based learning, teaching, fitting and rehabilitation will significantly improve the overall quality of outcomes for CI wearers www.monika- lehnhardt.net
  • 11. Rehabilitation •Methodologies currently applied working with children with CIs • Sign language • Cued speech • Total communication • Simultaneous communication • Guberina method • Natural Aural approach • Auditory verbal therapy www.monika- lehnhardt.net
  • 12. Rehabilitation Regardless of which methodology is applied – the most convincing argument is the success of the therapy: establishing hearing as an integral part of the child’s life, developing her/his communicative and verbal skills and improving them continuously over the years”. www.monika- lehnhardt.net
  • 13. Rehabilitation •Organization of rehabilitation for pediatric CI recipients • Fitting of the speech processor (5 weeks post-operatively, during 3 – 5 days, preferably in a CI Centre) • Therapy should comprise on average 12 days per year until the recipient reaches the age of 20. www.monika- lehnhardt.net
  • 14. Rehabilitation •Answers to selected country-specific questions From the range of issues related to rehabilitation of children with CIs, we selected seven important questions and searched the data in various European states for answers. We have uncovered very heterogeneous evidence! www.monika- lehnhardt.net
  • 15. Selected answers •Q1. Where does rehabilitation happen? • In Germany and Austria: inside the hospital or outside • Switzerland: in educational facilities • Spain: in schools • Portugal: two clinics offer rehabilitation in house (Coimbra and Estefania), all other is happening outside • UK: in and outside the hospital, in health care as well as in educational facilities. There are no special Cochlear Implant Rehabilitation Centres • Central and Eastern Europe: schools for the deaf • Czech Republic: clinic, schools, local facilities • Lithuania: educational institutions www.monika- lehnhardt.net
  • 16. Selected answers •Q1. Where does rehabilitation happen? • Poland: in clinics, healthcare facilities, Polish Association for the Deaf • Latvia: specialized healthcare facility • Bulgaria: hospitals, schools and also a special Centre for rehabilitation of CI recipients • Romania: in state-owned special schools for deaf children or in private individual speech therapy offices • Croatia: special centres for hearing impaired children or for children with additional impairments • Serbia: in some centers www.monika- lehnhardt.net
  • 17. Selected answers •Q 2. Is the surgeon globally responsible for the CI recipient or only for surgery The surgeon should take the overall responsibility! This is recognized in most countries (Germany, Switzerland, Poland etc.) In Central and Eastern Europe the surgeon is only responsible for the operation www.monika- lehnhardt.net
  • 18. Selected answers •Q 3. Is each professional responsible for his own activity only or is there one person with a global responsibility and who is it? Every professional is responsible for their work. Ideally, the head of the implanting clinic/coordinator takes overall responsibility. In Germany this is the case in clinics with a very high number of annual implantations. UK: a “key worker” to coordinate all activities, each professional is still responsible for their work. Poland, Latvia: one person with overall responsibility. Other CEE states: with a few exceptions this is not the case. Varese, Italy: trans-disciplinary approach. www.monika- lehnhardt.net
  • 19. Selected answers • Q 4. Is rehabilitation a health care activity or an educational activity? • Germany: a health care activity and paid for by the health insurance companies (Krankenkassen). • UK: a health care activity in the early phase and as an educational activity long- term. • Poland, Latvia, Bulgaria and Croatia: a health care activity because it is paid for by the Ministry of Health. • Czech Republic and Serbia: both. • Lithuania: an educational activity. www.monika- lehnhardt.net
  • 20. Selected answers • Q 4. Is rehabilitation a health care activity or an educational activity? I believe that rehabilitation of paediatric CI recipients and counselling of parents is an educational activity, regardless of where it happens. Only a few components like first fitting and regular adjusting of the speech processor programmes and obviously regular medical follow-up do not belong to the educational process. www.monika- lehnhardt.net
  • 21. Selected answers • Q 5. What about the educational background / degree of the specialist in rehabilitation for the deaf CI recipient? • Pedagogues for hearing impaired, logopeds, audio therapists, psychologists, ergo therapists, teachers, social pedagogues, music therapists, paedaudiologists etc. • Germany, Austria and Switzerland: no legal requirement for a special degree but most professionals have one in the field of special pedagogy. 90% are female. • The situation is practically the same in the UK, Spain and other Western as well as CEE countries. www.monika- lehnhardt.net
  • 22. Selected answers • Q 6. Who does the rehabilitation of deaf people? Hearing specialists or experts in communication from a more general point of view? Pedagogues who have the competence of sign language work in the rehabilitation for deaf people. We could call these experts in communication. For CI recipients it is in all countries specialists for hearing (but not necessarily medical doctors). www.monika- lehnhardt.net
  • 23. Selected answers • Q 7. Are there centres dedicated exclusively to deaf care in your country? Are there special centres for rehabilitation for CI recipients? • Germany: Schools for the Deaf  schools for hard of hearing; special Rehabilitation Centres for CI recipients; special institutions for early support and intervention (Frühförderung), special boarding schools and vocational training establishments • UK: special Cochlear Implant Rehabilitation Centres do not exist. Rehabilitation is provided in different places to support the development of spoken language and this is for children with hearing aids as well as for CI recipients. • CEE: special CI rehabilitation centres are an exception. www.monika- lehnhardt.net
  • 24. Landscape of global communication changed • Web-based Learning, Teaching, Fitting and Rehabilitation The Internet • a revolution in global information • geographical boundaries overcome • social impact: social networks, forums and environments • new possibilities for hearing rehabilitation www.monika- lehnhardt.net
  • 25. Landscape of global communication changed • Web-based Learning, Teaching, Fitting and Rehabilitation • LiveOnline Room: every participant (wherever she/he is) can become active at the same time by writing into the text chat and it becomes visible to all participants who are logged in including the presenter. • Three communication modes are possible simultaneously: listen and talk read and write, see and present. www.monika- lehnhardt.net
  • 26. Landscape of global communication changed • Advantages of post-operative care for CI recipients in a web-based environment • Independence of distance • Cost and time savings • Higher chance for increased frequency of “meetings” • Remote fitting www.monika- lehnhardt.net
  • 28. Thank you for your attention! www.monika- lehnhardt.net