Title of the case study: R.P. case; in-progress rehabilitation processes

General data on the case:

  • R. is a 20-month-old boy. He lives near Lisbon with his parents and his much older half-brother.
  • No family history of hearing loss.
  • Both parents are Portuguese, 43 years old, and employed.

    2. Case history (Anamnesis):

Significant medical data

  • Born at 36 weeks + 6 days gestation of normal birth. Planned and monitored pregnancy.
  • 24 weeks into the pregnancy there was a danger of premature birth and the mother was diagnosed with gestational diabetes. The rest of the pregnancy went on without further complications.
  • Received a “refer” result on newborn hearing screening.
  • Following discharge, R went to a private ENT who referred him to the Hearing Rehabilitation Consultation at the pediatric hospital (CHLC – Hospital de Dona Estefania).
  • At 4 months old, ABR indicated a bilateral, profound, sensorineural hearing loss.
  • Etiology: unknown

Significant psychological data

  • Appropriate development of motor and cognitive milestones.
  • Exposed only to Portuguese spoken language.

Educational setting:

  • R. stayed at home with his mother until September 2020. Since then, he’s been staying at his grandmothers’ alternatively.
  • He is currently waiting to be admitted to a regular daycare starting in September 2021.
  • Referred to Early childhood intervention Team to have support at home. Due to the current pandemic situation/Covid-19, this support only came in April 2021.

How often and what kind of support/rehabilitation does the child/family receive?

The Cochlear implant program is an interdisciplinary one. The members of the nuclear team are ENT, audiologist, speech therapist, psychologist and social worker. Other specialties such as neurology, genetics, developmental pediatrics, ophthalmology, among others, are also available for consultation when needed.

When a child/family arrives at the program all appointments, exams are scheduled according to the stage of the process that they are in at that time (e.g. diagnosis, decision call, evaluation, intervention…).

Currently R. undergoes an audiologic review every 3 months and has an appointment with the ENT every 6 months. He also has speech therapy every week and the psychologist talks with the family and observes the child on a regular basis.

3. The implantation

  • Fitted with bilateral hearing aids at 6 months.
  • Received bilateral cochlear implants at 11 months. The CIs were activated 4 weeks later.
  • The CIs are Sonnet 2 from MED-EL.
  • According to the parents, he uses the implants almost all day. Login data is in accordance with this statement.
  • In the first week after activation, he cried when the implants were switched on but he continued to wear them.
  • The audiological results from last review (April 2021) are:

RE – 500Hz: 20dB 1000Hz: 20dB 2000Hz: 20dB 4000Hz: 30dB

LE – 500Hz: 20dB 1000Hz: 20dB 2000Hz: 20dB 4000Hz: 20dB

Conditioning with Visual Reinforcement Audiometry (VRA) with Filtered White Noises.

4. What is the procedure for starting speech therapy after CI?

After the diagnosis, the ENT referred the child and his family for evaluation in speech therapy and psychology.

These first sessions were held together with the purpose of meeting the family and child, explaining and guiding the parents in the process of auditory rehabilitation, clarifying any concerns they might have, but also to get to know the family context, support and evaluate the child’s general development.

At that point, speech therapy sessions were scheduled in person whenever parents had to go to the hospital for consultations and/or examinations or by telephone (during the most critical phase of the pandemic).

5. The Speech Therapy used in rehabilitation

Following the family’s decision regarding the process of auditory rehabilitation and the mode of communication they desire for their child, the Aural Rehabilitation (speech/language) approach was agreed upon. With this approach, our main goal is to develop spoken language through hearing and speech, and speaking will be the primary means of communication and learning.

We use this approach in a family-centered way so at least one parent is always present at the sessions.

Since the activation in August 2020 R. has had weekly 50-minute speech therapy sessions at the hospital.

Currently, at 8 months post activation of both CIs the child is able to:

  • Listening development:
  • Localize the sound source with greater accuracy and at a distance
  • Localize different people talking
  • Respond appropriately to meaningful sounds (songs, his dog, cellphone…)
  • Associate some Learning to Listen (LTL) sounds with the correspondent toys or objects (train, food, dog, duck)
  • Recognize a few songs by doing the gestures when listening to music
  • Associate meaning with words from his day-to-day routine
  • Demonstrate auditory memory for familiar requests such as ‘say bye-bye’, and ‘give it to me’
  • Speech production development:
  • Imitate suprasegmental features (e.g., /oh/ for sadness, /uh-huh/ train)
  • Produce a variety of vowels and some consonant sounds (e.g. /p, b, m, d, n/)
  • Spontaneously produce consonant-vowel (CV) combinations and canonical babbles
  • Spoken language development:
  • Vocalize and gesture to request and/or protest and comment
  • Understand simple sentences like ‘it’s over’, ‘we are going home’, ‘don’t touch’
  • Understand simple questions within context. e.g., ‘where is the dog?’
  • Respond to early developing yes/no questions
  • Spontaneously produce some LTS sounds
  • Use some words (e.g. mamã, papá, olá /óa/, não /nana/, dá e avó /bó/)
  • Cognition and communication:
  • Make symbolic play of daily living.
  • Scribbling with pencils.
  • Drawn to books
  • Show curiosity toward new toys or objects
  • Demonstrate age-appropriate eye contact
  • Likes to play and engage in communication with known people
  • Initiate communication by pointing and sometimes vocalizing
  • Use greetings and farewells
  • Demonstrate different feelings (e.g., sadness, anger, surprise)
  • Monitoring of the progress in auditory, speech and spoken language development. How?
  • Integrated Scales of Language Development
  • LittlEars® Mede-el – Questionário auditivo
  • IT-MAIS: Infant-Toddler Meaningful Auditory Integration Scale
  • MacARTHUR-BATES Communicative Inventories
  • iLIP: Infant Listenig Process Profile
  • Registers of the observations made in the sessions
  • Parents’ reports

6. Results

• Auditory rehabilitation implemented at an early age
• Consistent use of CIs
• Family context
• Proximity of the rehabilitation team (audiology, psychology, ENT)      
Grandmothers cannot come to sessions.
Very anxious parents
The wearing of face masks (due to COVID-19)
• Parents attend sessions (family engagement)
• Guide and coach parents  
• Costs associated with CIs.
• Contact with the company representing the CIs (only one physical store and it’s far away)
• Unknown etiology