BOSCO, Ersilia

C. BARCHETTA

FILIPO, Roberto

MANCINI, PATRIZIA

English

Archivio della ricerca- Università di Roma La Sapienza

International Journal of Pediatric Otorhinolaryngology49 Suppl. 1 (1999) S183–S187Cochlear implantation in deaf children and adolescents:effects on family schooling and personal well-beingR. Filipo, E. Bosco *, C. Barchetta, P. ManciniENT Clinic, Uni6ersity La Sapienza of Rome, Policlinico Umberto I, Viale del Policlinico, 00161, Rome, ItalyAccepted 15 June 1999AbstractThe paper is an attempt to answer the main questions raised by that part of the deaf community which still considercochlear implants (CI) an attack against the psychophysical integrity of the pre-lingually deaf. Methods: Thepsychological well-being of six adolescents and six children was assessed pre- and post-implantation using varioustools, i.e. projective tests, assessment scales (AS), and structured interviews with parents and teachers. The analysisof post-implant findings shows a reduction of stereotype elements, more dynamic modes of figurative expression, quitegood relationships within their own social environment and gradual, positive integration both at home and at school.Cochlear implantation would seem to cause no psychological disruption. Our sample group show an improvement intheir modes of expression — more consistent with the mental and effective age — and a greater awareness ofpersonal limits, together with the ability to judge the appropriateness of their own behavior. © 1999 Elsevier ScienceIreland Ltd. All rights reserved.Keywords: Psychology; Projective tests; Assessment scales; Deafnesswww.elsevier.com/locate/ijporl1. IntroductionThe assessment of both the psychological char-acteristics and the educational environment ofprofoundly deaf children, candidates for cochlearimplantation, is common practice in almost allcertified cochlear implant (CI) centres [1]. Themain goals of such evaluation are: to avoid the non-use of the implant; to verify the presence of adequate educationalresources; to verify the existence of cognitive, space-tem-poral and behavioral pre-requisites (along withthe acceptance of limits and rules) and thebasic requisites needed for the development oflinguistic competence; to create a rehabilitation protocol tailored tothe specific needs of each subject.Non-use of the implant is an important elementwhich points to the uneasiness induced by variousfactors, including non-acceptance from an aes-thetic point of view or unpleasant sound qualityof the implant [2].The present study is an attempt to draw atten-tion to the ‘secondary effects’ of cochlear implan-* Corresponding author. Tel.: +39-64454607; fax: +39-64454864.0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved.PII: S 0165 -5876 (99 )00212 -8R. Filipo et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S183–S187S184tation that is, not so much the direct influence ofimplantation on hearing and language perfor-mance skills, as on the psychological well-beingof the subjects and their consequent integrationin family and educational surroundings [3]. Thisshould be stressed for two reasons: one, to an-swer the questions raised by that part of the deafcommunity who still consider cochlear implanta-tion an attack against the psychophysical in-tegrity of the pre-lingually deaf; and two, toassess the educational and emotional resourceslinked to CIs, considering that maladjusted be-havioral patterns can heavily interfere with learn-ing processes.2. Materials and methodsOf the total group of subjects who receivedcochlear implantation in our centre (35, of whom32 Clarion and 3 Med-E1 Combi Plus 40) 12were selected for our study: six adolescents (12–18 years, four males and two females, all Clarion)and six children (4–9 years, four males and twofemales, four Clarion and two Med-E1).All subjects underwent an accurate pre-implantassessment protocol, based on audiological, psy-chological, linguistic and educational data. Aftersurgery they underwent regular fitting sessions,along with language performance and psychologi-cal tests to assess progress [4].Since none of the standardized personality testscan cover all aspects of the personality alone, andowing to the extreme complexity of this field ofinvestigation, we decided to use various tools forthe definition of patient profile [5]. These includeprojective tests, assessment scales (AS) and struc-tured interviews within two basic contexts.2.1. Psychological well-being2.1.1. Projecti6e personality tests Draw a man [6]; draw a tree [7]; draw a house [2].2.1.2. Self-assessment scales Emotional instability (EI); pro-social behaviour (PB); physical and verbal aggressiveness (PVA) [8].2.2. Family/school integration2.2.1. Structured inter6iews With parents; with teachers at school (twice per year).2.2.2. Hetero-assessment scales Emotional instability (EI); pro-social behaviour (PB); physical and verbal aggressiveness (PVA) [8].As far as projective personality tests (PPT) areconcerned — carried out pre-implant and once ayear post-implant — the drawings were analysedtaking into account the quality of the graphicaspect, the presence of symptomatic elements andthe picture as a whole [9]. The following three ASare indicators of the child’s ability to establisha good relationship with his own socialenvironment: the EI scale measures the tendency of the childto experience states of uneasiness, insufficiencyand/or vulnerability as an expression of in-sufficient emotional and behavioural self con-trol; the PB scale measures the extent to which theindividual tends to offer help, to promote ini-tiatives involving other people and to sharepersonal objects and experiences; the PVA scale measures the degree of aggres-siveness, both physical (fights, assaults) andverbal (insults).These tools (AS) were applied to subjects above 7years of age, 1 year after implantation. In thiscontext the use of self-assessment questionnairesbrings to light the individual’s awareness of theexistence of possible behavioural problems, justas the use of hetero-AS (filled in by the parents,the teachers and the speech therapist) enables oneto fit information within a specific context and tostudy the differences between how the child es-teems himself and how he is considered by adults.R. Filipo et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S183–S187 S185Finally, the structured interviewing sessions (IS)were carried out by the clinical psychologist whointeracted with the parents and any other signifi-cant figure involved in the subject’s well-being. Infact, discussions usually stressed interpersonal re-lationships, educational problems both at schooland at home and emotional development. Thesessions took place at least twice a year or more ifparticular problems arose.3. ResultsResults obtained from projective tests and AShave been compared to normative data (obtainedon normal hearing children of the same agegroup) but have also been evaluated as intra-indi-vidual variation after one year of rehabilitation.3.1. Projecti6e personality testsThe results obtained from these tests can besummarized as follows:1. draw a man test: progressive transition to-wards an increasingly clearer sexual identifica-tion; expressions of various states of mind;normalization of the size of the figure of thehuman body (more active reaction to environ-mental pressures); gradual disappearance ofstereotype elements.2. Draw a tree test: constant reduction of stereo-types; correct placement of the drawing inrelation to effective age; further specific ele-ments (sawed branch, trunk/foliage propor-tions); gradual disappearance of superimposedelements e.g. fruit in the foliage.3. Draw a house test: presence of a base line(contact with reality); correct proportions ofthe roof (mental elaboration); solid wall struc-tures (well articulated psychological defencemechanisms); presence of doors and windows(availability for social relationships); variouselements — closed gate, fence around thehouse, winding path — which can indicate thepossible presence of difficulties in interper-sonal relationships.Therefore even though, over time, certain graphicelements — indicating the presence of problemsand specific characteristics — continue to bepresent, there is however a definite evolution ofthe modes of expression which become continu-ously more consistent with the subject’s mentaland chronological age. For example, in threeof the subjects in our group, the sawed branchelement — which generally indicates painful oreven traumatic experiences in the past — wasdrawn in a more articulate manner integratingbetter with the rest of the picture. Another ele-ment, that is the proportion between the foliageand the trunk of the tree — which points to therelationship between reason and instinct — staysthe same, even though what varies is the mode inwhich it is depicted (graphic elements becomemore detailed and harmonic). On the other handadditive and juxtaposed traits (fruit in the foliage,leaves on the branches in a very orderly andstereotyped manner), which are typical of draw-ings carried out by deaf subjects, are no longerpresent. It is interesting that those elements whichrepresent contact with the outside world becomeprogressively more numerous, complex and some-times disorganized. Furthermore, in the ‘Draw aHouse test’, the house itself tends to be morecontextualized (fitted within a specific landscape)and one can note the presence of elements thatindicate on the one hand problems with interper-sonal relationships and on the other an increase inpersonal defense mechanisms.3.2. Assessment scalesAverage values of self- and hetero-AS havebeen compared to normative data obtained fromnormal hearing children of the same age group.The small numbers of subjects tested to date andthe lack of a homogeneous control group onlyenables us to offer a description of basic scores.It is evident that the mean data for implantedsubjects both for the self- and the hetero-ASwould seem to show no significant difference fromthat in normal hearing subjects (Tables 1 and 2).Furthermore a greater difference in mean datacan be seen between self- and hetero-assessment inour study group as opposed to that in normativefindings (Table 3).R. Filipo et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S183–S187S186Table 1Self-assessment scales: comparison of means and S.D.s forimplanted and normal hearing subjectsaEI PB PVA19.12 (3.89)Normal 19.48 (2.68) 15.54 (4.21)hearing21.16 (2.48) 20.00 (1.63) 17.17 (17.17)Implantedsubjectsa S.D. in brackets.4. DiscussionFrom the analysis of findings it is evident thatcochlear implantation causes no psychologicaldisruption. On the contrary, even taking intoaccount the differences due to personal experi-ences, the drawings show up a constant reductionin stereotype and mechanically drawn elements.After implantation it became evident that therewas a greater tendency to place the main figurewithin a specific context, using richer details andmore dynamic modes of expression; at the sametime there were some graphic elements whichindicated lack of order and difficulty in interper-sonal relationships. This last mentioned findingcan be considered a positive factor since it indi-cates a greater awareness of personal limits andconfirms that the subject is beginning to take noteof various new aspects of reality [10].The results for the Assessment Scales showedthat the implanted subjects were able to adapt tochanging situations almost as well as normal hear-ing subjects. The greatest discrepancies betweennormal and implanted subjects was however to befound in how the subjects evaluated themselvesand how they were considered by the adults. Infact the children in the study group tended toconsider themselves more inadequate and vulnera-ble in comparison with the assessment given byteachers and parents. This could be attributed tothe characteristic under-esteem typically found indeaf subjects. Furthermore, feelings of insuffi-ciency and vulnerability are typical of adolescentswho, in our study group, made up the majority(75%) as opposed to the composition of the con-trol group where they were only 24%. Howeverour results indicate that even implanted adoles-cents are good judges of the appropriateness oftheir own behavior.The future development of a normative groupthat also includes deaf children and the increase inthe number of subjects in our study group willenable us to elaborate a more significant statisticalmodel.The information obtained during structured in-terviews has enabled us to follow up the gradualand positive integration of implanted children athome and at school. Indication of active adapta-This would seem to indicate a greater dis-crepancy between how implanted subjects evalu-ate their behavior and how in turn this is assessedby adults, in comparison to the tendency in thenormal hearing group. However one variable thatshould be taken into consideration is the fact thatthese profoundly deaf subjects inevitably hadfewer speech skills even though all the items usedwere previously illustrated to them and accuratelyexplained.3.3. Structured inter6iewsFrom the structured interviews with parents,teachers and/or speech therapists in this context,we will only mention the behavioural traits of theimplanted children which they believe to be di-rectly linked to the use of the implant.Children: tell lies, answer when called, ask why,are able to wait, are more attentive.Adolescents: answer when called, take part indiscussions, are interested in what happensaround them (home, school), want explanations,greater respect for rules, play around with peers,offer solutions, are more constant.Table 2Hetero-assessment scales: comparison for means and standarddeviations for implanted and normal hearing subjectsaEI PB PVA18.51 (5.90) 13.12 (5.00)Normal 19.29 (3.87)hearingImplanted 18.57 (2.60)18.24 (4.45) 14.80 (2.26)subjectsa S.D. in brackets.R. Filipo et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S183–S187 S187Table 3Comparison between mean data for self- and hetero-assessment scales in implanted and normal heanng subjectsPBEI PVAHetero Self HeteroSelf Self HeteroNormal hearing 19.12 18.51 19.48 19.29 15.54 13.1218.24 20.00 18.57Implanted subjects 17.1721.16 14.80tion can be seen in the fact that these childrenshow annoying behavior (tell lies, making excuses,making a lot of noise) which is, however, typicalof their age group and as such is to be considered‘normal’.References[1] S.A. Hellman, P.M. Chute, R.E. Kretschmer, The devel-opment of a children’s implant profile, Ann. Deaf. 136 (2)(1991) 77–81.[2] L. McKenna, The psychological assessment of cochlearimplant patients, B. J. Audiol. 20 (1986) 29–34.[3] D.Y. Aplin, Psychological assessment of multi-channelcochlear implant patients, J. Laryngol. Otol. 107 (1993)298–304.[4] E. Bosco, D. Ballantyne, M.T. Argiro, Rehabilitationprocedures adapted to adults and children, in: D.J. Allum(Ed.), Cochlear Implant Rehabilitation in Children andAdults, Whurr Publishers, London, 1996, pp. 180–198.[5] E. Bosco, La valutazione psicologica del bambino ipoacu-sico, in: M. Fabiani, R. Filipo (Eds.), La Sordita Infantilenel Sistema Sanitario Nazionale, Acumetron, Roma.1991, pp. 157–160.[6] K. Machover, Il disegno della figura umana, OS, Firenze,1970.[7] K. Koch, Il reattivo dell’albero, OS, Firenze, 1986.[8] G.V. Caprara, C. Pastorelli, C. Barbaranelli, R. Vallone,Indicatori della capacità di adattamento in età evolutiva,OS, Firenze, 1992.[9] M. Vernon, D.W. Brow, A guide to psychological testsand testing in the procedure of evaluation of deaf endherd of hearing children, J. Speech Hearing Dis. 29 (1964)123–134.[10] E. Bosco, La diagnosi funzionale del bambino ipoacusico,L’ educazione dei Sordi 1 (1991) 13–24..

Cochlear implantation in deaf children and adolescents: effect on family schooling and personal well-being

https://iris.uniroma1.it/bitstream/11573/138161/1/adolescents%20int%20j%20ped%201999.pdf

Cochlear implantation in deaf children and adolescents: effect on family schooling and personal well-being

Abstract

Similar works

Full text

Available Versions

Archivio della ricerca- Università di Roma La Sapienza