Psychological Risks in Childhood Cochlear Implantation

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The following editorial was written by Robert Pollard, Ph.D., psychologist at the University of Rochester Medical Center, at the request of a local Rochester newspaper. It is up to date as of February 1993.

Psychological Risks in Childhood Cochlear Implantation

Cochlear implantation, recently featured on 60 Minutes and Doogie Howser, M.D., is a controversial surgical technology being used to treat profound deafness in adults and children as young as age two. The "tail" end of the mouse-shaped implant is fed into the cochlea of the inner ear while the thin "body" end is secured in bone beneath the skin. Outside, a microphone worn behind the ear passes sound information to a computerized processor, usually worn at the hip, which in turn sends electrical signals to the implant. Postsurgically, most patients experience sound sensations but they are limited and distorted in nature, not like normal hearing. Many months are then spent in aural rehabilitation, learning to utilize the new sounds.

Much of the criticism regarding cochlear implantation has arisen from the American Deaf community. Some focuses on how implants reinforce pathological views of deafness rather than views of Deaf life as independent, promising, and emotionally fulfilling. Other criticisms concern the child's autonomy and relate to the complex and sometimes painful history of deaf- hearing social dynamics (e.g., the oppression of sign languages). Hearing people sometimes find it difficult to appreciate these Deaf community views and the occasional vehemence with which they are expressed. Yet, beyond the socioculturally driven criticisms, there are other reasons for concern regarding childhood cochlear implantation, especially from a psychologist's perspective.

The central questions (and parental hopes) regarding the surgery's outcome are, broadly speaking, psychological: Will the child achieve more in school...be happier and more socially successful...form closer bonds with family members...have better self-esteem and mental health...find greater vocational options and success in adulthood? Unfortunately, the research which could provide answers to these critical questions (especially in contrast to less intrusive medical, educational, and psychosocial interventions) has not yet been conducted. Without such research, parents are left to presume or hope that the enhanced audition that usually follows implantation will eventually translate into a better education for their child, greater happiness or social success. The danger in making this leap of faith is that it incorrectly assumes that the implant, at worst, will be psychologically benign -- that it cannot lead to harmful educational or social-emotional consequences.

Critics from the Deaf community note that the implant may impair a child's self-esteem, their body image, or the quality of the child's and family's acceptance of the hearing loss. These points are well taken. The device itself becomes an integral part of the child's body, something that sets them apart from others, including deaf peers. Implantation is a deeply personal event, one that the child must reinterpret at each stage of their social and sexual development. The risks are even greater when the implant does not result in substantial auditory benefit. While dramatic changes are never guaranteed, they are always hoped for. How will the child and the parents react to average or below average audiological outcome or one that does not translate into accelerated educational or psychosocial progress? Will they feel like a failure or that they have wasted the family's finances, time, and emotional resources? Will they drive themselves too hard during the long postsurgical rehabilitation phase, neglecting other aspects of the child's or the family's psychosocial development?

There are additional risks associated with how the implant may effect parents, siblings, and teachers. The family may become less devoted to signing or oral communication strategies because of the presence of the implant. In school, the child's need for communication and other support services may be less vigorously pursued. A child who could benefit from a sign language educational environment may have such a placement denied or unduly delayed while the effectiveness of the implant is slowly evaluated.

The FDA has decided that cochlear implants are no longer experimental, even though these critical psychological outcomes and risks remain virtually unexplored. Anyone involved with this new technology should recognize this as a serious deficiency, as well as the reality that a leap of faith is being made with every implant -- not only in hopes for the procedure's psychosocial and educational value but in the assumption that it will otherwise be psychological benign. Until proper research is conducted, no such safety or benefits can be reliably assumed. In my view, when parents, medical personnel, and advocates of this technology fail to acknowledge and contemplate these risks, they are in violation of their legal and ethical responsibility to demonstrate fully informed consent before initiating a significant medical intervention for a minor.