Issues Related to Communication Mode and Language Outcomes for Children with Cochlear Implants

The issue


Cochlear implants (CIs) are a common intervention for children with profound hearing loss. CIs provide individuals with access to spoken language input and have a positive impact on speech, language, and reading outcomes. Cochlear implant technology has resulted in significant changes in how we approach communication for children who are deaf. Accompanying these changes is a frequently debated topic among parents, researchers and professionals: the choice of communication modality for children with CIs, specifically bilingual/bicultural, auditory-oral, and total communication approaches.

What we know

Among the three main instructional methods, the bilingual/bicultural (bi-bi) model is the one most often selected by deaf parents who use sign language. In bi-bi models, children learn sign language (for example, American Sign Language) as their first language and written English as their second language. There is limited research on the topic of bi-bi education and CIs, mainly because the goals of sign bilingual approaches may not complement the goals of CIs, which are to promote the acquisition of spoken language skills. The few relevant, published studies were conducted in countries that used sign bilingual programs for most of their students who were deaf (for example, the Netherlands and Norway). Results suggested that for children with CIs, those who had more exposure to spoken language with sign support outperformed their peers enrolled in sign bilingual programs on measures of spoken language production.

Most of the research looking at communication modality and outcomes for children with CIs has focused on two approaches:  Auditory-oral and Total Communication. Auditory-oral (OC) approaches advocate for the use of speechreading and audition for communication, to the exclusion of signs.  Total communication (TC) is a philosophy that combines auditory, manual, and vocal modes, with the goal of ensuring effective communication by the child. Between the 1970s to the 1990s, TC was the most frequently used approach in educational settings for children who are deaf. Approaches to intervention underwent a major shift with the advent of CIs in the mid-1990s, however, with an increased emphasis on OC approaches to intervention.

Currently, most studies point towards advantages for in spoken language outcomes for children with CIs in OC settings. The results these studies should be interpreted with caution, however, because more advantaged children tend to enter OC programs (i.e., children from higher economic backgrounds, with more available resources, and/or children who show an early inclination towards success with spoken language). Positive speech and language outcomes for children with CIs also depend on a number of factors aside from communication modality, including how much residual hearing children have before receiving a cochlear implant, children’s ages at the time of implantation, how often children wear their CIs and/or hearing aids on a daily basis, and the parents’ goals for communication and overall development.

What we don’t know

Despite many strong opinions to the contrary, no one has yet produced evidence that sign language prevents children from developing spoken language, especially when it is utilized early in development.  Future research should address the issue of using sign or speech during the initial stages of language learning, and its effects on later language, reading, and psychosocial development.  Because of the substantial lowering of the age of identification and intervention over the past 10 years, this line of research is now feasible.


The findings of previous research studies on communication mode in children with CIs have important implications for families.  First, the data indicate that children can benefit from CIs regardless of their communication modality.  Second, it is critical that parents and service providers take several factors into consideration before deciding if one intervention approach is preferable to another.  Variables such as age at implantation and communication modality interact with one another.  While one intervention approach may be appropriate for one child, it might be entirely inappropriate for another child, depending on the parents’ goals and the child’s intervention history.

Another point that should be considered is that most children’s chosen communication modes are not frozen in time. In the long run, children with CIs will rely on the communication mode (spoken language or sign language) that is preferable to them as they adjust to the electric signal that the CI provides. Families with a newly diagnosed child should keep in mind that early decisions about communication approaches are not fixed for life. Instead, it may be more appropriate to introduce signed communication in combination with spoken language, in order to lay a foundation for later communication development.

Posted on January 12, 2015 by
Elizabeth A. Walker
J. Bruce Tomblin
Department of Communication Sciences and Disorders
University of Iowa
elizabeth-walker {at}

Further reading

Davidson, K., Lillo-Martin, D., & Chen Pichler, D. (2014). Spoken English language development among native signing children with cochlear implants. Journal of Deaf Studies and Deaf Education, 19, 238-250. view details

Mitchiner, J.C. (in press). Deaf parents of cochlear-implanted children: Beliefs on bimodal bilingualism. Journal of Deaf Studies and Deaf Education, published online September 18, 2014. view details

Walker, E. A., & Tomblin, J. B. (2014). The influence of communication mode on language development in children with cochlear implants. In M.M. Marschark, G. Tang, & H. Knoors. Bilingualism and Bilingual Deaf Education (pp. 134-149). New York, NY: Oxford University Press. view details