From birth through about three years of age, each second represents the creation, by the brain, of seven hundred to one thousand additional neuronal connections- Dana Suskind, Thirty Million Words
Thirty Million Words: Building a Child’s Brain is a book about early childhood development and immediately had me interested. The title is a reference to the findings of a groundbreaking study performed in the 1990s by Betty Hart and Todd Risley. They found that the cumulative difference between the number of words heard by children from professional families vs. children from the welfare families at the end of three years of age was close to thirty two million. As Suskind writes in her book, the study showed with statistical force that the preliminary factor in what would eventually become known as the “achievement gap” was the difference in early language exposure. The thirty million word gap is really about the brain and its development.
Few pages in, I learn that the author, Dana Suskind is a pediatric cochlear implant surgeon. Well can’t get any more relevant, right? A few more pages into the book my excitement starts dwindling, giving way to uneasiness. Suskind describes ‘The cochlear implant is a puzzle piece that fits, just so, a miraculous solution to total deafness’. Yes, cochlear implant is a miraculous solution to total deafness. It is a miracle that my severely to profoundly deaf child is able to experience sound and dance to music. However, cochlear implants are not a ‘solution’ to all kinds of deafness. Only deaf with favorable anatomy qualify for or benefit from cochlear implants. This key information is often missing. For example, while Suskind highlights the miraculous technology, she never mentions its limitations. One could argue that the book is about harvesting the benefits of the technology, mentioning its limitations will be out of context. That’s where I would draw a parallel from my real life experience. During the first few months of our visits to the ENT and audiologist while the cochlear implants were thrown as a solution to us in the very first meeting, it took several follow-up visits to find out who really could benefit from them, what is the process of determining the candidacy for our son, what will be the limitations of the technology even after/if they proved successful for Shreyas. In fact it was only the deaf school which gave us the key information that we won’t know until our son is a year and a half or more whether he got enough benefit from the cochlear implants to develop conversational hearing and speech. This is where the rest of Suskind’s book becomes even more pivotal.
‘By the end of age three, the human brain, including its one hundred billion neurons, has completed about 85 percent of its physical growth, a significant part of the foundation for all thinking and learning.’
This finding is so crucial and significant. Earliest approved CI surgery age for babies by the FDA in the United States is 9 months although surgeries have been performed sooner in many cases and much later in others. For babies with congenital deafness, by the time their implants are activated and they start to respond to conversational sounds, they are close to the 1 year mark. They have already missed out on 1/3rd of the crucial window of brain development. In many cases the response time is even longer and the families are asked to be patient and hopeful of the positive outcome. If a child is not benefitting enough from the CIs, by the time that realization sinks in for the parents, more crucial time from the critical brain development window is lost. Even if the family wants to choose the exclusive oral communication path through cochlear implants for their deaf child, sign language plays an important role in the first year of their life. Addressing language needs for deaf babies during the 0-1 year period of their life even if they are a potential candidate for a successful cochlear implant is a discussion which very much needs to happen.
Suskind goes on to write ‘when it’s successful, the startled expression of the child followed by a smile, laughter, or even crying. It is an extraordinarily moving experience. See for yourself. Simply search YouTube for “cochlear implant activations” and wait for the tears.’ Only if Suskind had also advised the readers to also scroll through the comments on the said videos, one would know that they have received generous amounts of flak from both the deaf and hearing community. Even the audiologists attest to the fact that they set false expectations. CIs do not turn on a sudden switch to hearing. Shreyas’s response on his activation day was so subtle that only our audiologists could read his bodily cues. Contrary to Suskind’s suggestion of ‘Simply search YouTube’ our team had explicitly suggested that we not get carried away by ‘those’ videos. It took a good 6-8 weeks before we could see a definitive response to sounds from our son.
Suskind makes various arguments about why Cochlear implants are a better ‘solution’. To me, cochlear implants are a crucial tool which provide access to sound. That in itself is a big deal in a primarily hearing society which runs on listening and spoken language. I am thankful everyday for the technology that they are and what they mean to my son. Many times I forget that he is deaf and that hearing to him is not the same as what it is to me. Yes, they are miraculous but they do not have to be proven to be everything else.
‘Given the costs of special education, underemployment, and unemployment, deafness is one of the most expensive of disabilities. The cochlear implant is an essential key to avoiding that cost’, writes Suskind. Cochlear implants are not cheap, they do not work like a miracle for everyone. She writes elsewhere in the book that ‘Sign language can provide a rich, early language environment when provided by fluent signers‘. However, the idea of risking one’s child’s language and hence brain development on the outcome of cochlear implants just because the parent is not a fluent signer is even a riskier proposition in my opinion. Learning sign language is easier and more affordable than it was a generation ago due to the availability of online classes and free you tube videos . To the point of socioeconomic status supporting the wealthier ease of time and money to learn a new language, CIs are not free either. In absence of insurance coverage it is thousands of dollars for the surgery and then continued speech therapy. Talk to any CI team and they would say that the actual work starts after the surgery and continues for years after which is also an added financial burden. The equipment is also expensive to replace if lost or stolen.
While those are the evident reasons why the book makes me uneasy, there are other subtle ones too. For example the disproportionate use of the word mother versus parents in understanding and taking the ownership of the child’s early language development. It can be argued that specially in the lower socio economic group that Suskind is talking about, usually mothers are the primary caregivers. However the book is a vision to change things from their current default. I envision the responsibility of bridging the thirty million word gap to rest equally with both the parents. On another occasion, I wondered why Suskind had to bring up Alexander Graham Bell without any relevant context? I wondered if it was a mere coincidence or pretentious ignorance? As a person only recently exposed to the history of the American Deaf, the irony of using his example is not even lost on me. To quote from Katie Booth’s book, The Invention of Miracles, “When my grade-school social studies book said that Alexander Graham Bell was the inventor of the telephone, it sounded as absurd to me as introducing Adolf Hitler as a vegetarian who once ruled over Germany”. [In full disclosure, I am currently reading Booth’s book and nothing against Bell so far. The point being why open the can of worms for no good reason?]
I am no expert either in the field of language nor Deaf history. I am a parent who is often worried about the choices I make for my child. My opinions are based on my personal experiences so far. The story in retrospect is yet to be seen. However, I cannot help but wonder how a book by an ENT pediatric surgeon while calling cochlear implants miraculous forgets to mention their limitation, how the surgeon who advises about getting an early implant to facilitate language development can be ignorant about the importance of language in the first year of a baby’s life (happed to us for real), how while writing about the technology of today being mundane tomorrow the only reference that Suskind could think of is Alexander Graham Bell? Suskind’s book does a great job of spotlighting the early language development but it is also a one sided commentary about cochlear implants. As a mother of a deaf child with bilateral cochlear implants, I cannot look away from the subtle biases and unintended misguided information. And when it comes to the thirty million word gap, I believe Deaf or hearing, CIs or not, it is possible to bridge it. When I found out that my baby boy was deaf, I promised myself that I would learn to sign all the books that I had ever read to my daughter before he turned 9 months old. I told his ENT pediatric surgeon that I cannot give my son the ability to hear and I cannot ensure that he is a good candidate for cochlear implants but I can and will make sure that he will always have age appropriate language. I am not saying that I have always known the right things to do. I also acknowledge that I am privileged and fortunate in many ways. I am sure that in my parenting journey I will make wrong choices and make many mistakes. I am just glad that missing out on the crucial language and brain development window for my child is not going to be one of them.