Division of Developmental and Behavioral Pediatrics, University of Michigan Medical School, Ann Arbor, MI.
Division of Developmental and Behavioral Pediatrics, Boston Medical Center, BU Chobanian & Avedisian School of Medicine, Boston, MA.
J Dev Behav Pediatr. 2024;45(5):e497-e500. doi: 10.1097/DBP.0000000000001308. Epub 2024 Aug 13.
Gretta is a 3.5-year-old girl with a history of congenital cytomegalovirus, congenital bilateral profound sensorineural hearing loss (SNHL), and bilateral vestibular dysfunction, resulting in frequent falls. She underwent cochlear implantation at 12 months of age and was diagnosed with autism spectrum disorder at 2.5 years of age.On presentation for follow-up in the developmental-behavioral pediatrics (DBP) clinic, Gretta's mother reports that Gretta has refused to wear her cochlear implants for the past 5 months. Before that, she seemed to enjoy having access to sound and like dancing to music, and her receptive and expressive language skills, including speech, were progressing. Initially, the rejection of her devices occurred only at preschool. When frustrated or overwhelmed, she would close her eyes and remove her devices for up to 5 minutes before allowing them to be reapplied. Over time, this progressed to a complete refusal to wear her devices at school and then at home, rendering her without access to sound and spoken language.Gretta's mood has become sullen, and she is now having tantrums at school. She physically startles when attempts are made to reintroduce her devices. Her ability to participate in classroom learning or interact with her classmates is limited, as she attends a spoken-language-focused preschool program. A board-certified behavioral analyst, hired by the family, recommended that Gretta not be allowed to participate in classroom activities unless she wears her devices. She now becomes visibly anxious even when in the same room as her devices and repetitively states "no implant, no implant." Her mother is worried about her inability to communicate and has "no idea" what may have changed or sparked her initial refusal to wear the devices.What factors would you consider when determining the cause and function of Gretta's refusal to wear the cochlear implants? How would you guide her parents, teachers, and clinicians to ensure the best developmental and behavioral outcomes for her?
格雷塔是一名 3.5 岁的女孩，患有先天性巨细胞病毒感染、先天性双侧重度感音神经性听力损失（SNHL）和双侧前庭功能障碍，导致经常摔倒。她在 12 个月大时接受了耳蜗植入手术，并在 2.5 岁时被诊断为自闭症谱系障碍。
在发育行为儿科（DBP）诊所进行随访时，格雷塔的母亲报告说，在过去的 5 个月里，格雷塔拒绝佩戴她的耳蜗植入物。在此之前，她似乎很喜欢听到声音，喜欢随着音乐跳舞，她的接受性和表达性语言技能，包括言语，都在进步。最初，她只是在幼儿园时才拒绝佩戴这些设备。当感到沮丧或不知所措时，她会闭上眼睛，摘下设备，最长可达 5 分钟，然后再重新戴上。随着时间的推移，这种情况逐渐发展到她在学校和家里完全拒绝佩戴设备，使她无法听到声音和语言。
格雷塔的情绪变得忧郁，现在在学校里发脾气。当试图重新给她戴上设备时，她会身体受惊。由于她参加的是一个以口语为重点的学前项目，她参与课堂学习或与同学互动的能力有限。一位家庭聘请的认证行为分析师建议，除非格雷塔佩戴设备，否则不允许她参加课堂活动。现在，即使在她的设备旁边，她也会明显感到焦虑，并反复说“不植入，不植入”。她的母亲担心她无法沟通，“不知道”是什么改变了或引发了她最初拒绝佩戴设备的行为。
在确定格雷塔拒绝佩戴耳蜗植入物的原因和功能时，您会考虑哪些因素？您将如何指导她的父母、老师和临床医生，以确保她获得最佳的发展和行为结果？
