Even as one source of the controversy is resolved, others emerge. There remains little concern about the effectiveness of cochlear implants as a sensory aid for both adults and children. Given appropriate candidate selection and follow-up, cochlear implants provide adequate auditory input to enable a young child to develop functional oral language and speech. Yet the conflict remains. By doing just that, it has been suggested that the use of cochlear implants violates United Nations conventions against limiting the growth of linguistic minorities. The question that must then be answered is: which is more important—the best interest of the individual child, or the best interest of deaf culture? It is a question any parent can easily answer, but it cannot be agreed upon by ethicists.

Another controversy with which cochlear implant teams struggle on a routine basis is that of candidacy criteria. Evidence continues to mount that children in aurally based oral rehabilitation programs derive greater measurable benefit from cochlear implants than do children receiving visually based rehabilitation. Yet, if it is indeed a parental decision as has been argued by implant proponents, can implant teams refuse to implant children based on the rehabilitation mode? Is the implant team's responsibility fulfilled by informing the parents that the child will be unlikely to derive maximum benefit from the device in the current rehabilitation setting, or does the implant team have the right to deny the child an implant based on their own beliefs? An issue that remains controversial today is the age at which children should be considered for implant surgery. For many years, the age of 2 was accepted as the lower limit for implantation. As both implants and means of identifying infant hearing loss have improved, that limit has been challenged. In fact, the FDA recently recommended that the age limit be reduced to 18 months. There seems to be indication that younger is better, but no one is sure if there is a lower age beyond which the benefit decreases. Theories of early critical periods of language learning would seem to support earlier implantation, whereas the difficulty in quantifying and estab lishing the quality of residual hearing in infants together with surgical concerns continues to remain deterrents to implantation below 18 months.

Controversy has been a fact of pediatric cochlear implantation from the beginning. Efficacy, safety, ethics, and candidacy issues have all been sources of controversy at one time or another. As one source of conflict is resolved, another arises. The future may see controversy arise over such issues as best device choice, use of bilateral implants, and whether to save a better ear for future developments, such as hair cell regeneration.


Hodges et al.—CHAPTER 79

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Cochlear Implants in Congenitally Deaf Children*

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