Introduction

In the age of neuroscience, communication can now be mediated through neuroprosthetics like the cochlear implant (CI). The CI links one's nervous system, specifically the auditory nerve, to an implanted array of electrodes that is connected to and managed by a microprocessor. Thus, spoken communication or speech in its acoustic signal is translated into a digitized form and communicated via electrodes that fire an electrical signal to the auditory nerve. This article will discuss this neuroprosthetic as a specific form of mediated communication and a technoscientific object that has an accompanying social infrastructure. This infrastructure exists in multiple, coordinating institutions that systematize its usage. (Blume 2010, Mauldin 2012) Here I focus on how the CI-tailored classroom is systematically reconfigured for optimizing the use of this communication technology.

Certainly the CI has been controversial and is a familiar topic for work in Deaf and disability studies, which critiques a pathological view of deafness. (Brueggeman 2008, Christiansen & Leigh 2002, Gertz 2008, Lane 2008). For example, in the CI world, language is almost exclusively defined as spoken language. Based on this definition, the logic that follows is as such: those without access to spoken language, such as children who are identified as deaf, can and should be implanted with this biotechnological device that can provide the necessary mediation, thus remedying the problem. (Blume 2000, Tucker 1997) However, using the social model of disability, it has been argued that communication is not exclusively spoken and that signed languages are equal to spoken languages, deafness is not inherently a 'problem,' and Deaf culture and identity are important to foster. (Crouch 1997, Ladd 2003, Lane 1996, Bahan & Lane 1998, Sparrow 2005) Simultaneously, the CI is also celebrated by parents of deaf children, professionals, and adult users as a liberating and potentially promising mode of mediated communication. (Aronson 1999, Chorost 2005, Tucker 1995) However, despite the seemingly clear divide over CIs, pro-CI and anti-CI groups should not be homogenously pitted against each other. Gradual shifts in these constantly moving social relations towards a middle ground have certainly been documented. (Leigh 2010, Woodcock 2001)

While acknowledging that the CI is a new iteration of the centuries-long attempts to intervene upon deaf bodies — that is, it is but one more chapter in the story of medicalization1 — I will not focus here on building an argument for either side of the controversy. Instead, I want to turn to the empirical because, despite critiques of their use, the statistics clearly indicate that the CI is a mediation tool that is increasingly being utilized. (National Institute on Deafness and other Communication Disorders, 2009) I chose to see the statistics on their use as a tool that could give me a clue as to where to begin unearthing data. My goal: to describe and better understand what the introduction of CIs into society looks like. As a result of this goal for my research, I conducted fieldwork in a CI clinic and focused on pediatric implantation in children under the age of six.2

This article will specifically describe one aspect of my fieldwork, which is how the deaf education classroom is becoming an arm of the CI clinic and extension of clinical practice. Here, I give a picture of the highly organized social forces accompanying the CI and how they act as behind-the-scenes structures shaping classroom practices. As CIs are a relatively recent phenomenon, we are just beginning to be able to look back on the last ten years of routinizaton. This is intended to begin the process of uncovering that story.

The expansion of implantation and related practices

The expansion of implantation is the result of many factors. Firstly, ninety percent of parents with deaf children are hearing, (NIDCD 2010) thus deaf infants are not born into an available sign language system or environment. For a variety of well-documented reasons, parents turn to implantation and its necessary, long-term rehabilitation efforts in the hopes that the child develops spoken language despite his/her deafness. (Christiansen & Leigh 2002) Current practices in implantation then emphasize that long-term therapies and educational methods should all coalesce around the CI. (Bradham et al 2009) As a result, the CI has also benefited from supporting institutional practices in the clinic, home, and school; creating a conducive environment for the expansion of implantation.

One of the objectives in Healthy People 2010, a nation-wide health promotion plan from the Department of Health and Human Services, is to, "Increase the proportion of persons with hearing impairments who have ever used a hearing aid or assistive listening devices or who have cochlear implants." (NIDCD, 2009) In addition, there have been drastic changes in the age of identification in infants. In 1993, only five percent of children were screened for hearing loss, while today more than ninety percent of infants born in the US are screened. (Meadow-Orlans 2004) This results in earlier identification and leads to earlier implementation of Early Intervention services. These services are mandated by the Individuals with Disabilities Education Act (1990/2004) and implemented in every state. They are available from birth until age three; infants are provided multiple services, many of which are now tailored to and specifically developed for optimizing implantation. These state-based programs have developed alongside a trajectory of biotechnological developments in the devices themselves as increasingly sophisticated models of CIs are manufactured.

Deaf education and implantation

Gabel (2006) proposed the question: "Who decides which policies and practices are applied to the education of D/deaf (or disabled) students?" As outlined above, implantation is encouraged and institutionalized from the top-down, from federal mandates to state programs. Situated within the states are clinics, individual families, and the services they consume. Gabel also states that:

It would appear that distributive systems—in this case, the system resulting from IDEA—gets to decide when it comes to disability and education, this is only a symptom of what is determined through intense socio-political negotiations between and among stakeholders within historical and economic contexts, while the power relations that circulate invisibly throughout such negotiations tweak and twist the results. (2006)

The systemization of implantation then has created a variety of stakeholders, all of which contribute to the implementation of communication technologies in deaf education. For example, there has been a proliferation of associated service sectors, professions, and industries that circulate around the CI. In turn, as the data shall illustrate, these are utilized by local school districts as they devise ways to integrate implanted children who use spoken language into mainstream school settings. I hope to address some of Gabel's questions below.

Certainly, the history of deaf education is fraught with controversy and is highly charged and complex; arguments over teaching methods have tended to be deeply ideological. The divide has largely been between auditory/oral instructional methods that emphasize spoken language. Those who support auditory/oral methods typically adhere to the philosophy that "all or most deaf children should be taught this way exclusively." (Bayton 1996:13) What follows is the belief that sign language, which would be categorized as 'manualism,' often called Total Communication (TC), to teach deaf children should be avoided. Most of deaf education history then has been the repeated cycle of adopting different types of oralist efforts in an effort to promote proficiency in spoken language.3 Luterman (2004) gives an informative overview of the trends in deaf education and, like him, "I realize writing about the methodology issues in education of the deaf is fraught with peril." (2004: 18) However, my main goal here is to describe what is happening in one particular program as it relates to the use of mediated communication technology.

CIs, like previous oral educational methods, are still based on a representation of auditory information. However, it is a digitally simulated and customizable version of sound that is directly fed into the auditory nerve; it is the most sophisticated form of representation to date. That is, it simulates auditory reality in a way that has not been achieved before. Education in this highly representational and digital context is not simple and involves a complex array of strategies, technologies, and services. Adequate and effective transmission of this mediated form of communication requires a tremendous amount of effort to deliver, as well as a tremendous amount of effort to train the 'listener' to 'decode.' That is, the CI is not a self-evident device; it exists within a host of contingencies. As Irene Leigh writes, "How advantageous technology is for human interaction depends on the technology, the specific populations being affected, and the social context." (2010:152)

In an effort to better understand this social context, I want to pay close attention to the related industries that implantation spawns and how it is quickly diversifying and multiplying the players involved in the field of deaf education. Particularly salient, though not new or surprising, is the 'listening and spoken language' (LSL) sector, often called 'auditory/oral' or 'auditory-verbal' (AVT). "Some states have documented that parents are choosing the listening and spoken language outcome as high as nine out of ten cases." (Murphy 2009:22) To answer Gabel's question (2006), in the case of deaf education today, I would argue that the healthcare system, along with its partnership in various other professional sectors, increasingly decides through its offering of biotechnologies like the CI. In 1997, Murphy (2009) notes that a mere sixteen percent of elementary and secondary students with hearing loss were aiming for spoken language acquisition. But this was before implantation became a common clinical practice. "Today seventy-three percent of elementary and sixty-eight percent of secondary students are learning through spoken language. That's a dramatic shift to occur over just one generation." (Murphy 2009:22) What follows is a description of one program that illustrates goals of customization (determined by medical prescription) and shows how the supporting services and industries involved in the education of an implanted child are put in place in the classroom.

Although my ethnographic fieldwork initially started in a CI clinic, it led me to a host of related sites. During my time in the clinic I shadowed audiologists, the social worker, and the newborn hearing screening coordinator. I conducted multiple informal interviews with these individuals on the clinical staff, as well as met numerous parents of children with CIs and interviewed them multiple times. The clinic also ran a support group for parents, where I met one particularly active parent and CI community advocate. She then agreed to introduce me to the world of auditory/oral deaf education that has sprung up around implantation. This, however, is only one clinic and one school in and around one city (New York). It is merely a case study and certainly there are multiple reasons for the strong interconnections between institutions, such as their geographic proximity to each other and the preeminence of the CI clinics located in this city.

Interconnections

One Monday morning, I arrived at the home of Nancy4 , whose child was implanted fourteen years ago. Since then, she has become an active member of the CI parent community and an advocate for support services for both deaf children in oral educational programs as well as their parents. I met Nancy at a parent support group one night. She was there at the clinic providing guidance and advice to parents with newly diagnosed or implanted children. On this morning, she was escorting me to a local school, which has one of the strongest and pioneering programs for the oral education of deaf students in the nation.

Her home was nestled in a middle-class residential, suburban area of New York City. The phone immediately started ringing as she ushered me inside. On the phone was one of her colleagues at the Alexander Graham Bell Association5 (AGB) who was collaborating with her on a CI-related conference. She discussed the information for the brochure, hung up, and then the phone promptly rang again. She discussed more details with another colleague and then proceeded to tell me about her AGB community listserv and contacts in various undergraduate programs for audiologists and speech-language pathologists in the region. She sometimes visits these programs to present on how important oral education of the deaf is and that all deaf children do not need sign language, as many seem to think. I ask her how she knows so many people and has so many contacts. "When you've been in it this long, you know everyone."

I probe further, wanting to understand how these interconnections happen. She tells me "It depends. Sometimes [CI clinic social worker] will call me and say can you speak to this person? A lot of them meet me at the support group. From the school here, she [principal] will tell parents to call me." She goes on to explain her and the principal's involvement in AGB. Because of this, the school is also a site for AGB-sponsored dinners for parents. "We have AGB meetings at the school because most hearing impaired kids will get services from these schools," she tells me. "But I'm at the dinners that we do, I'm at the meetings, I'm at the open houses, you know, so…and even some of the teachers here have called saying they have a family that has some questions, would you mind speaking to them." She also works as a fundraiser for other schools that provide oral education methods. As we pull up to the school, she says, "It's a pretty small community."

The school looks like any other elementary school, there are colored pieces of paper on the walls with drawings and I can hear the teachers' voices spill out into the hallway as they conduct their classes. There are eighty children at this elementary school, more than half of which have a CI. The Department of Education is trying to prepare for the continually rising numbers of students whose parents want these kinds of services, and this is one of the programs they have been paying attention to. At the back of the corridor is the principal's office. Nancy leads me over to her door and the two of them greet each other warmly; they have an easy rapport. Nancy introduces me to the principal, Linda, and the three of us walk through the hall, peering into rooms as they both explain the set up to me.

Techno-mediated classrooms as extensions of the clinic

In the first classroom we come to, the teacher has a variety of empty plastic film canisters filled with different items. All of the children had hearing aids and/or CIs6 and were using spoken language. The task at hand was to shake the canister and based on the sound it makes, determine what is inside. I watched as one implanted child guessed correctly: pennies. I also immediately notice that the teacher is wearing a microphone and that there are speakers mounted at various points in the room. In the nineties, oral programs depended solely upon sound field systems, which consists of a microphone, a 'base station' and multiple speakers. The teacher wears the microphone, which takes the acoustic signal and sends it to the base station, which then transmits this to the speakers located throughout the room. This ensures that the auditory information is being distributed equally to all areas of the room and that all children are immersed in the sound field.7

Linda explains that "About five years ago, they switched over to personal FMs…Now a personal FM is one where the teacher is wearing the mic and the children have their own FMs in their implant." These personal FMs, which operate through radio waves, can also be used with hearing aids or CIs. The signal can be transmitted directly into the child's CI microprocessor through a special jack that is mounted on the CI. Linda explains, "So you're seeing both — you're hearing through the sound field. But the children also have direct input." This individualization of technology results in using classroom equipment to meet each student's particular audiological needs, which are defined not by the educators, but by medical professionals. "So it's very tailored…that's going to depend on the type of hearing loss they have and the audiological recommendations." Linda goes on to say, "I was happy we were individualizing, and that we had the sound field, and each child had his own system."

The implant center plays an integral role in classrooms of this CI program. The recommendations for classroom adaptations come directly from the clinic; making the school yet another arm of the clinic and extension of medical practice. Hence, the classroom is a prescribed environment. Some implant centers will "send their people here to do mappings8 for the kids." This is one of the pioneering collaborative efforts in this program that has caused many in the oral education of deaf students to take notice. "So you can choose to — if you were implanted at [center], you can choose to go there to have it done. Or you can make the arrangements when the person comes here, to do that." This is in addition to the educational consultants that are on staff at implant centers. These consultants, often termed "educational consultants in a medical model," work for the implant center. For school-aged children who are candidates for CIs, they will visit the child's current educational placement to assess the accommodations, which is used in determining CI candidacy and ongoing efficacy of the implant. However, the audiological services at this school are much more sophisticated. "These are the actual audiologists from the implant centers. They schedule time to come here, and they do the mappings onsite…It's a partnership."

As we turn the corner, we arrive at the audiologist's office, which is a couple of doors down from the classrooms. There is an entire wall full of tiny plastic clear drawers. In these are cables, coils, jacks, spare parts, electrochords, electromagnets, and batteries. The audiologist has to be able to replace any part of any child's hearing aid or CI at any given moment. Each child's education is now dependent upon technological objects to mediate spoken communication and the education program is purposefully integrating each student/patient's needs. The principal continues: "It used to be everybody had one [hearing aid] ear and you just made the molds and that was education of the deaf…That was the old style of deaf ed." But, she explains, that when she took over this program the first thing she instituted was a full time audiologist so that every child can have his/her personal system, which "is a prescription from the center audiologist." She wanted it to be much more precise and much more tailored to the students, so that their educational/communication method reflected their medical prescription. "Obviously it meant a huge paradigm shift, from a generic application system to customizing the FM or sound field or systems to the hearing aids or the cochlear implants…. And the whole idea is that you want it to be customized as precisely as possible."

CIs and hearing aids are not separate cases anymore, although the audiologist explained to me that, " We definitely have more kids with implants than hearing aids, at this point. It's swung. In the past couple of years, it's definitely made a turn." Furthermore, there is a large number of students who wear amplification on both ears, whether it is a combination and CI and hearing aid or two CIs or two hearing aids. There has definitely been "a swing toward bilateral as well."

Mediated communication and classroom collaboration

As the children come up through the program, they are integrated into the 'regular classrooms' in the elementary school that this program is attached to. The kind of classroom pioneered here is referred to by the principal as a collaborative classroom. This is "a mixed classroom with both a teacher of the deaf9 and a regular education teacher." Thus, the students are immersed in an "integrated environment" and benefit from a smaller student-teacher ratio. Not only are there two teachers in each classroom, but, "the curriculum is the standard [state] curriculum, with just whatever legal mandates are available for the hearing impaired and deaf, within the classroom — extra time on tests." Nancy speaks up here with a point that she stresses is extremely important to her, "They do not dumb down the curriculum for these kids. My daughter takes the regular, standard [state test]…They're not, "Oh poor deaf kid." You know?" Linda adds that, "In the old days, they were so segregated, and there are still programs — like [local deaf school that uses sign language]…When you go into a classroom, the teachers of the deaf have no idea what the general ed expectations are for the children at that grade level. Because they're not immersed in it; it's not their fault."

Teachers of the deaf

The notion of a "teacher of the deaf" is an entry point to illustrate how the context of implantation is not just a form of mediated communication, but also a force that is generating a new meaning of this role. During my time at the school, Nancy and Linda continually referred to their teachers of the deaf. I had to inquire about what teachers of the deaf offer in the classroom as it was not apparent to me. I indeed saw two teachers in the room, but I saw nothing particularly 'deaf.' There was no sign language and all of the children appeared to use spoken language, as did both of the teachers. The principal explained to me that, "they are sharing and supplementing and modifying and accommodating and doing all the things to make this a successful placement." I was not sure what this translated into, as I associated the term teacher of the deaf with sign language. Furthermore, when I observed a collaborative classroom in action, the children with CIs and the hearing children were indistinguishable, and the regular education teachers and the teachers of the deaf were barely distinguishable. Linda even noted that "Many times, when I'll point them out, I'll ask, "Who do you think is the teacher of the deaf?…Ninety-nine percent of the time they don't know." This is because the CI provides the access to the spoken language world, but the educational infrastructure supporting here it is intended to enrich and constantly reinforce this language. To illustrate the subtlety, Nancy tells me this story:

One time I brought someone here, when [her daughter] was in second grade. And the teacher of the deaf was explaining something…as she explained it, she said, "Okay. Now we're going to look at this door. And I'll just give an example. The door is open. What's another word for 'open?' 'Ajar.'"…They just pull out much more vocabulary, much — they make the connection with language, so that — in reading, in math, whatever they do — it's really language enriched….The teacher of the deaf also makes sure that when a certain concept is being taught — maybe she'll have visual supports, like charts and pictures and things…and add more to the multi-sensory feel of the classroom.

As noted before, the field of deaf education is varied. The formal training for the kind of educational method seen here is auditory-verbal therapy (AVT) or auditory-verbal education (AVed). According to the principal, speech therapists typically are certified in the former, while teachers of the deaf are certified in the latter. From the above, it is clear that it is not just intended to provide children with the access and ability to understand and use speech, but to take it further with the goal of providing nuances.

These teacher certifications, which are specializations that individuals attain to work in these kinds of programs that are tailored to CI-related educational methods, are obtained through AGB. It should also be noted that they regularly partner with CI companies for various programs and events, emphasizing the interdependence within the technology, the industry, healthcare, and education. According to their website, "The AG Bell Academy for Listening and Spoken Language is the global leader in certification of listening and spoken language professionals." As an organization that has continually proliferated, especially as CIs have become more common, it has a powerful stake in creating and maintaining professions that grow directly out of implantation.

"Completely separate"

The end of my tour occurred at a building across a field a short walk away. As we walked over, Linda explained that we were going to the part of the school which did not employ these technologies or methods. Speaking about their separation from one another, she says that when she started the program and "I was doing in-service with staff for the auditory/oral, the TC staff kind of felt like they were left out. I would provide in-service for the TC staff, and the auditory/oral teachers would feel left out. So I recognized that you really cannot have both modalities in one program." There are about half as many students in these programs that she supervises and it does continue to grow. Knowing that the rate of implantation is ever-increasing, I asked how it could be that pedagogical methods employing sign language would still be growing. The reason, she explained, is directly related to the access to implant technology:

We have so many families coming in from other countries…. And the children are seven and eight years old…they've never learned auditory/speaking…They have missed the auditory development stage, which is 0 to 6. That's the critical stage for learning to listen through the auditory channel. If you miss any portion of that, it's very difficult to catch up….it's very difficult to expect a child of seven and eight to catch up auditorially. So we give them sign language.

At this particular site, these programs, TC and auditory/oral, are professionally, geographically, and ideologically separated. As Linda follows up, "They are completely separate." But I found this to be true in my fieldwork in general; echoing Blume's (2010) findings on implantation and education, the professional consensus was that these had to be mutually exclusive. Although this is not a new idea, what is new is how it is being rationalized systematically in relation to implant technology.

Conclusion

Data here indicate some of the specific ways in which "cochlear implants and neonatal screening have catapulted the deaf child into the auditory-verbal camp." (Luterman 2004) Although I have not discussed outcomes or efficacy of these programs here, it is certainly a rich and needed site of research and analysis. But what is clear is the orientation toward technology and the promotion of customization. And like other types of enhancement technologies, there is a feeling that this form of mediated communication, specifically because of its feature of customization, is seen as "more powerful, precise, targeted, and successful — powerful because they are grounded in a scientific understanding of bodily mechanisms." (Rose 2007:20) Secondly, faith in its precision and success is ushered through discourse that illustrates how we have moved from simple normalization techniques to complex systems meant to achieve customization. (Clarke et al. 2005) As seen above, this results in efforts to make the CI and its surrounding environment as precise and individualized or targeted as possible. Not only this, but programs and teaching methods continue to be even further separated from each other because of ideological differences and animosity. Technologies like the CI exacerbates these tensions: those who advocate for manualism are not only maligned for their identity politics, but also dismissed because their lack of interest in CIs is interpreted as advocating for a kind of 'technological ghetto.' (Ott et al 2002)

This educational context then is medicalized and technologized in a very specific way; it is achieved through a means of simulated audition and a mediation technique that demands management by medical professionals. This is seen in the constructions of the classroom as an extension of clinical thinking and space where a child's 'prescription' be executed, creating the classroom-clinic. To go back to Gabel's question of 'who decides' - the infrastructure for deaf education is biomedically and biotechnologically defined. As mentioned earlier, there are many reasons for this, but implantation is continually legitimized through iterations of health and technoscientific discourse.

There is nothing particularly new about the role of medicine in education, especially in special education. But with all this focus on mediated communication through CIs, what is the status of the other side of the deaf education debate? What is the role of sign language (as CIs are certainly not guaranteed to 'work')? The general ethos that I found during my fieldwork in the CI community is that sign language is an un-mediated form of communication that, if adopted, renders people unable to be 'independent' in the world or able to succeed in an auditory/oral setting. This is a powerful epistemology of implantation and belief system about deafness that deserves more attention, and I am certainly not the first to suggest this.

One practical problem with these practices is the fact that CI 'success' has yet to be clearly medically defined. There are no established clinical criteria for measuring success or traditional outcomes data. This is a problem that needs to be addressed. Yet, there is a community-based understanding of what 'success' means, as well as an ethic of 'putting in the work' to achieve it. I have seen the fruits of this labor. Many deaf students I observed were indistinguishable from their hearing peers. I met many who would be considered a CI success story in that they listen to and speak spoken language. Thus, the goal in such programs is not to socialize a deaf child, but rather disintegration and/or redefinition of the 'deaf' or 'hearing impaired' qualifier entirely. That is, through technologies like the CI it is hoped that this characteristic is so mediated that it is no longer perceived by others. This new type of attempt to socialize the child is centered on this mode of mediated communication. This is a goal which should be thought about on a very deep level; what is the resulting, new ontology of the deaf child?

I am not making arguments for or against CIs and auditory/verbal educational methods using the traditional tools of identity politics. Rather, I argue that the thinking on this issue should be grounded in empirical data: Who is getting implants? How are they being educated and how does this break down according to race, class, gender or geographical location? As implants are inevitably increasing, the focus should also be on measuring efficacy: What are the outcomes of implantation? How are these outcomes measured? And what of the interconnections between organizations, educational institutions, CI corporations and healthcare providers? Who is benefiting here and what role does this play in this process? Given answers to the above questions, what is the role of sign language?

We need research based on these questions so that the field of disability studies and Deaf studies can have a strong understanding of what the current landscape is; the futures of deaf children depends on this, as these are the social issues that will face the upcoming generation. I would also point out the stratification of education methods based on immigration status or access to medicine. As the principle stated, the reason sign language continued to be used in school was because of the presence of children of immigrants who arrived "too late" to really benefit from CI technology. What kind of social stratification is happening here and what are the long-term implications? Given that immigration is a major topic of social concern, we should also be prepared to analyze CI statistics as they relate to differences in race/ethnicity and immigration status.

As the principal told me, "In life, as an adult, when it comes time to get employed, that is going to be their gift. The fact that their speech and language and their ability to converse is one of their strongest areas — that could have been taken away, if they had not had that option [to learn spoken language]." But, she also told me that, "We think that deafness is going to be a thing of the past someday in the future." These are powerful words and implantation is supported by a powerful set of resources and practices. Based on this, how do we think about the role of mediated communication as it relates to Deaf and disability studies? What new questions should we be asking?

My intent was to describe what is often left out of the implant debate in Deaf and disability studies, which is an understanding of what is happening on the ground in the CI community, what the implementation of CIs looks like, and how this empirical data can inform what kinds of questions disability studies and Deaf studies scholars may need to be asking.

Here, I hoped to have told a story of one type of device, as well as acknowledge that it is also the story of an auditory, techno-mediated communication usurping that of manual or signed communication. The question remains: Where do we go from here?