Correspondence

Cochlear Implants

N Engl J Med 1993; 328:1786-1788June 17, 1993

Article

To the Editor:

The editorial by Dr. Balkany on cochlear implants (Jan. 28 issue)1 makes outdated and incorrect assertions about American Sign Language and the education of deaf children. Dr. Balkany claims that Public Law 99-457 mandates treatment for hearing loss. It actually mandates access to public education. In the case of deaf children, access can mean not only mechanical aids to increase hearing, but also visual instruction using a natural signed language.

Dr. Balkany cites a 1977 article by one of us2 to compare a hearing five-year-old's vocabulary of 5000 to 26,000 words with a deaf child's vocabulary of 200 spoken or signed words. He states that the lack of a written form for American Sign Language is one reason for the low reading levels of deaf adolescents. This ignores history. For most of the past century, education of the deaf has focused on spoken English. American Sign Language was used by deaf people in private but was forbidden in school. It was sometimes punitively repressed3.

Recently, an alternative theory has been proposed to explain students' poor achievement. Cognitive development depends on exposure to language in the critical years of early childhood, when the brain is primed to develop language4. It is the emphasis on spoken English, which is not easily accessible to the young deaf child, that may lead to academic failure. Some believe this preventable form of linguistic retardation may be permanent4.

Interest in bilingualism is growing in the education of the deaf. American Sign Language has been established for 25 years as a linguistically complete, natural language. This curriculum encourages early exposure to that language. English (reading, writing, and -- for those who can speak -- speaking) is taught as a second language. Research indicates improved academic performance in deaf students taught with this approach5. Deaf children born to deaf parents and exposed to American Sign Language from birth have higher academic achievement than deaf children born to hearing parents6.

Dr. Balkany concludes that cochlear implants should be encouraged for deaf children. There is no evidence yet that the imperfect hearing provided to a congenitally deaf child by a cochlear implant allows spoken language to develop normally7. To advocate the use of implants in children is to present incomplete information. The enthusiasm of physicians, the media, and the public for such implants has more to do with society's love of technological answers and its difficulty accepting physical and cultural differences than it has to do with scientific evidence of efficacy.

Michelle D. Holmes, M.D., M.P.H.
Cambridge Hospital, Cambridge, MA 02139

Marie Jean Philip, B.S.
Warren A. Schwab, M.Ed.
Learning Center for Deaf Children, Framingham, MA 01701

7 References

1. 1

   Balkany T. A brief perspective on cochlear implants. N Engl J Med 1993;328:281-282
   Full Text | Web of Science | Medline

2. 2

   Schwab WA. Effects of hearing loss on education. In: Jaffe BF, ed. Hearing loss in children: a comprehensive text. Baltimore: University Park Press, 1977:650-4.
   

3. 3

   Lane HL. When the mind hears: a history of the deaf. New York: Random House, 1984.
   

4. 4

   Sacks OW. Seeing voices: a journey into the world of the deaf. Berkeley: University of California Press, 1989.
   

5. 5

   Davies S. Bilingual education of deaf children in Sweden and Denmark: strategies for transition and implementation: a report to the World Institute on Disability, September 22, 1990. Washington, D.C.: Gallaudet Research Institute, 1990.
   

6. 6

   Moores DF. Educating the deaf: psychology, principles, and practices. Boston: Houghton Mifflin, 1978.
   

7. 7

   Lane HL. The mask of benevolence: disabling the deaf community. New York: Alfred A. Knopf, 1992.
   

To the Editor:

Balkany minimizes the criticisms of childhood cochlear implantation made by members of the deaf community by framing them as uniformly based on the assumption that hearing parents are “incapable” of determining what is best for their deaf children. In reality, the National Association of the Deaf1 and others, both deaf and hearing, who are critical of implants consistently focus on the educational and psychosocial risk factors of the devices and on related inadequacies of research.

There is also no reason to believe Balkany's assertion that some deaf adults have limited ability to read English because American Sign Language has no written form. Numerous studies demonstrate that deaf adults raised to communicate orally, who know no sign language, have similar reading limitations, whereas children of deaf parents who use sign language actually perform better in English and other subjects than deaf peers from hearing families2. Early fluency in American Sign Language provides a medium through which cognition and learning are enhanced.

Robert Q. Pollard, Jr., Ph.D.
University of Rochester Medical Center, Rochester, NY 14642

2 References

1. 1

   National Association of the Deaf. Cochlear implants in children: a position paper of the National Association of the Deaf. NAD Broadcaster. March 1991:1.
   

2. 2

   Lane HL. The mask of benevolence: disabling the deaf community. New York: Alfred A. Knopf, 1992.
   

To the Editor:

We share the concern of Dr. Balkany about the limited vocabulary of many young children who are deaf. However, many now think this reflects a lack of access to training and education in manual or oral communication, rather than any deficiency of sign language. Deaf infants begin developing the first elements of manual language before the age of one year.1 When they are comprehensively exposed to sign language before the age of five, they can develop vocabularies and written-language skills more comparable to those of their hearing counterparts. It is important that parents be made aware of such options, including those available in preschool.

. . . At this time, cochlear implants are an expensive intervention, often with very limited effectiveness, that should probably be used only in research settings in which outcomes can be evaluated critically. Strong interdisciplinary teams are needed to inform candidates or guardians fully of the options and provide long-term support. For many people, current cochlear-implant technology fails to fulfill their dreams, but we hope there will be continued advances that will indeed benefit many in the future.

David A. Ebert, M.D.
University of Illinois Hospital and Clinics

James Vanderbosch, Psy.D.
Fred M. Levin, M.D.
Mount Sinai Hospital, Chicago, IL 60612

1 References

1. 1

   Petitto LA, Marentette PF. Babbling in the manual mode: evidence for the ontogeny of language. Science 1991;251:1493-1496
   CrossRef | Web of Science | Medline

Author/Editor Response

The author and two colleagues reply:

To the Editor: American Sign Language is a natural language with its own syntax, phonology, and lexicon. It is an excellent, expressive, often eloquent method of face-to-face communication. However, American Sign Language has no written form; it is not a signed form of English. Thus, deaf children must learn English in order to read and write.

Theories that stress the use of American Sign Language and minimize that of English ignore the fact of unacceptably low reading abilities among deaf schoolchildren who are already fluent in signed language1. Learning English adequately without hearing is a formidable task that is facilitated by cochlear implants.

Some deaf adults can now understand up to 100 percent of words spoken in sentence context by using their cochlear implants, without signed language or lip reading2. More important, most children with cochlear implants develop a functional level of hearing that substantially enhances the development of spoken English3. In discounting the effectiveness of cochlear implants, the correspondents overlook the current body of scientific literature. The safety and efficacy of cochlear implants have been demonstrated by hundreds of refereed scientific papers, by research sponsored by the National Institutes of Health, and by an exhaustive decade-long review by the Food and Drug Administration.

Pollard exaggerates phantom “risk factors” that have not appeared in more than 7000 adults and 3000 children who have received cochlear implants, including more than 400 in our collective experience. The correspondents misconstrue Public Law 99-457, which, along with its progenitor, Public Law 94-142, recognizes that even mild hearing loss can cause developmental delays and requires access to the least restrictive environment. (Among potential teachers, employers, or neighbors, less than 0.2 percent, or 1 in 500, will be primary users of American Sign Language4.) Their misleading historical perspective ignores the past three decades, in which signed language has played a central part in deaf education.

To restate the undisputed: Over 90 percent of deaf children are born into families with normal hearing. Despite their best efforts, most family members do not master signed language. American Sign Language has no written form. Unless English (or Spanish, or another language) is taught, deaf children will not adequately learn to read. Cochlear implants enhance the ability to hear spoken English, not to mention a mother's voice, an automobile horn, a smoke alarm, a siren, and music. Implants are a therapeutic option, not intended for all deaf people and not at all antithetical to American Sign Language.

Nonetheless, physicians must continue to be the advocates of patients, not of a language or a form of technology. Parents have the right and the responsibility to learn about all options and to make choices for their children. What is disturbing is an organized effort to abrogate this choice by suppressing the use of cochlear implants5.

Thomas Balkany, M.D.
University of Miami School of Medicine, Miami, FL 33101

Noel L. Cohen, M.D.
New York University School of Medicine, New York, NY 10016

Bruce J. Gantz, M.D.
University of Iowa, Iowa City, IA 52242

5 References

1. 1

   Conrad R. The deaf school child: language and cognitive function. New York: Harper & Row, 1979.
   

2. 2

   Wilson BS, Finley CC, Lawson DT, Wolford RD, Eddington DK, Rabinowitz WM. Better speech recognition with cochlear implants. Nature 1991;352:236-238
   CrossRef | Web of Science | Medline

3. 3

   Miyamoto RT, Osberger MJ, Robbins AM, Myres WA, Kessler K, Pope ML. Longitudinal evaluation of communication skills of children with single- or multichannel cochlear implants. Am J Otol 1992;13:215-222
   Medline

4. 4

   Sign languages. In: Gallaudet encyclopedia of deaf people and deafness. Vol. 3. New York: McGraw-Hill, 1987:43-53.
   

5. 5

   Pollard R. Alert, implants. (New England Journal of Medicine.) In: DEAFTEK, USA. (Electronic mail publication MGJD-5633-2854. February 4, 1993).