Expert opinion: Assessing cochlear implant candidacy and progress for people with English as an additional language

Abstract

Special considerations relating to cochlear implants (CIs) are necessary for deaf people for whom English is an additional language (EAL). The audiological and pre-linguistic skills criteria for CI candidacy are the same for children with EAL as for children from English-speaking families. However, thorough assessment is not straightforward, for example, requiring employment of experienced interpreters. To ensure family engagement and thus appropriate support in the home, clear understanding of the family's social and cultural framework and of their needs and requirements is essential. Equally, the family must be enabled to understand the implications of CI. Additional training of staff in CI teams may be needed. This article will address these and other issues for children and also consider the situation for adults.

Introduction

Deaf children from families where English is an additional language (henceforth EAL deaf children) have to fulfil the same audiological and pre-linguistic criteria for cochlear implantation (CI) as do English-speaking children. However, delivering a rehabilitative intervention package that includes CI must be done within the EAL deaf child's cultural and linguistic context in order to maximize benefit. This means that the values and beliefs of each EAL deaf child's family must be taken into consideration to ensure that intervention is responsive to the needs of what is a culturally and linguistically diverse client group (Leigh and Crowe, 2015). For hearing impaired adults with EAL, the clinical team also faces the challenge that the candidacy criterion is based on a speech perception task (BKB sentences) which contains sentences with very predictive content. Adults with English as a first language (E1L) are able to use higher level cognitive skills when assessed on the BKB sentences to fill in missing words. This is not so straightforward when English is not the first language because the linguistic rule structure may not be as sophisticated as for native speakers. There may also be cultural aspects that make the sentences less relevant for some adults from diverse cultural backgrounds.

EAL deaf children: demography

Long-term immigration as well as current migration trends contribute to the wide-ranging cultural and linguistic diversity in the UK. In some minority UK communities there is a higher incidence of deafness (Thomas et al., 2008). In 2009, Bajaj et al. found that for a variety of reasons, in children of Bangladeshi origin, the prevalence of sensorineural deafness was at least 2.3 times higher than the national average. In newly arrived groups, where disadvantage may be greater, there is likely to be a higher rate of deafness for reasons such as undiagnosed problems and untreated middle ear disease, as reported in Australia by Leigh and Crowe (2015).

EAL deaf children: languages

The annual survey conducted by the Consortium for Research into Deaf Education (CRIDE) shows year-on-year that there are significant numbers of EAL deaf children in the UK, particularly in multicultural urban environments. In the most recent 2013 survey (CRIDE, 2013) which specifically investigated languages, of the 37 371 deaf children for whom information was available, 7.2% were reported to have a language other than English at home. This could be an underestimation, however, since several services were unable to provide information on the languages spoken by children in their area, leaving 7804 children for whom no information about languages was available. The numbers of EAL deaf children with CI's is not routinely documented. Mahon et al. (2011) showed that at one London CI Centre audited over 5 years (2003–2008), 28% of children receiving implants were from EAL families, speaking languages such as Urdu, Bengali, Gujarati, Turkish, Somali, and Arabic, similar to the proportions of people speaking languages other than English in London at the time (DCSF, 2008). The latest UK Census figures (ONS, 2013) however, show a rise in the number of people speaking other languages such as Polish. The challenge for professions in assessing language development and skills, and in providing appropriate interventions comes with the fact that many families speak variants and dialects of languages about which not much is known such as Mirpuri, Sylheti, Albanian, Roma, to mention but a few.

The Newborn Hearing Screening Programme in the UK (NHSP, n.d) applies equally to children from all language groups and is a significant factor in early diagnosis and intervention for every child who needs a CI. As there is no similar screening programme for adults, early and appropriate access to CI services for them is less likely and proportions reaching the CI clinic are far lower than for children.

EAL deaf children: Language development and use

Given the multifaceted interrelationship between culture and language, coupled with the additional complication of deafness, the development of spoken language in EAL deaf children can seem like an impossible task. In most cases, however, the children do acquire a spoken language – usually English, due to early interventions which are generally delivered in English. Whilst this is necessary for progress through the UK education system, there are drawbacks: EAL deaf children frequently do not acquire their family language and as they grow up this can be detrimental to family relationships (Crowe et al., 2013). EAL families in the UK are usually bi-or multilingual, speaking their family language as well as some English. The pattern of language use in the family, and the family members’ proficiency in the languages used, depends on numerous facts like how long they have lived in the UK, where they were educated, etc. With the benefit of a CI, the EAL deaf child will be exposed to all the languages used by family members, having access to direct speech and to overhearing the incidental talk going on around them. This is known to benefit language development (Hoff, 2006). There is growing evidence that with sufficient exposure to languages, EAL deaf children particularly those who have CIs, can acquire two spoken languages (McConkey Robbins et al., 2004; Thomas et al., 2008). The crucial factor is the provision of appropriate language development support for the child and for the family. Such support should also take into consideration the family's intentions and choice in regard to their children's use of multiple languages at home and at school (Leigh et al., 2010).

EAL deaf children: language assessment

The planning and execution of appropriate support and intervention is crucial, but knowledge about languages and culture is not always available to professionals (Mahon et al., 2011). Also lacking are the skills and tools to assess linguistically diverse deaf children and provide support for families (Cline and Mahon 2010; Guiberson and Atkins, 2012). There is the further challenge in the lack of normative information about language development in linguistically diverse children. The dearth of assessment materials in the UK in languages other than English is well documented (Cattani et al., 2014). This matters right from the start, for example, with the assessment of an EAL deaf child's pre-linguistic skills, mentioned earlier as being a key CI candidacy criterion. Frequently, pre-linguistic skills are assessed by way of parental checklists using tools such as the Early Support Monitoring Protocol (DfES, 2006) or the Children's Communication Checklist CCC-2 (Bishop, 2003). For the families of EAL deaf children, these tried and tested parental report methods can be tricky and the results may not be secure. For example, parental proficiency in English will influence the results if the checklist has to be read and responded to in writing; if the checklist has been translated, there may be concerns about validation of the translated version. Ideally, translators and interpreters should be properly trained.

EAL deaf children and adults: support by professionals

In the NHS England Action Plan on Hearing Loss (NHS England, 2015) there is clear endorsement for delivering culturally and linguistically appropriate intervention for both children and for adults. The stated aims include the provision of ‘person-centred planning, which is responsive to information and social needs’ and the promotion of ‘inclusion and participation, by ensuring that all public services are accessible and support language and communication needs’ (NHS England, 2015, p. 6). The document further states that one of the outcomes specifically for deaf children and young people is ‘support for good language acquisition…for the child and their family, to facilitate effective communication’ and ‘to address the attainment gap for children and young people by ensuring appropriate language acquisition, communication and learning support in the early years and throughout education’ (NHS England, 2015, p. 15).

Ensuring that appropriate strategies are used with a diverse client group presents an enormous challenge in a busy clinic setting; additional training and/or information-gathering may be necessary. First to ensure that access to CI is not reduced through lack of understanding about the process, insight into the way the clients and their family would seek help is needed. Skilled interpreters are essential to carefully explain the CI process to families so that they can weigh up the pros and cons, and make the right decision for their child. Once potential candidates are on board, the team needs to build ‘cultural competence’ into their rehabilitation strategies, taking family attitudes about deafness and language choice into account. To do this, CI teams could work with cultural advisors and/or informed members of a particular family's cultural/linguistic group. The CI team must ensure that the family understand and are fully cognizant about the device: good device management at home is one of the key factors in the child deriving full benefit from the CI.

In order to level the playing field for EAL deaf people, it is not simply a case of professionals treating every candidate and their family in the same way, but to treat each in an appropriately different manner.

Disclaimer statements

Contributors None.

Funding None.

Conflicts of interest There are no conflicts of interest among the authors.

Ethics approval None.

ORCID

Merle Mahon http://orcid.org/0000-0001-9075-9739

Debi Vickers http://orcid.org/0000-0002-7498-5637