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Hearing loss has far-reaching, critical effects on childhood development of cognitive (thinking) and linguistic (language) skills. The occurrence of other disabilities in combination with diminished hearing creates "additional learning problems" which significantly add to the complexity of educating the student who is deaf or hard of hearing. The prevalence of other disabilities in addition to hearing loss is approximately three times as large (30.2%) in the deaf or hard of hearing population as in the general school population. Some of this may be explained by the varying causes of hearing loss. Some of the current documented etiologies of childhood deafness include maternal rubella (2%), prematurity (5%), cytomegalovirus (1%), and meningitis (9%)(Moores, 1987). It is logical to assume that the population demonstrating a hearing loss is at a high risk for additional disabilities since the previously mentioned etiologies are also known to be associated with neurological involvements.

The prevalence of several specific disabilities occurring with diminished hearing has been documented over time (Craig & Craig, 1993, 1983, 1973). The three additional disabilities most often reported in children who are deaf or hard of hearing are learning disabilities, intellectual disabilities, and emotional/ behavioral disabilities. The 1993 reference issue of the American Annals of the Deaf reports learning disabilities as the largest co-occurring disability at a prevalence of 9%. The prevalence of intellectual disabilities occurring with a hearing loss followed closely at 8%. The co-occurrence of emotional/behavioral disabilities was the least at a 4% occurrence rate.

Although there are difficulties in definitively characterizing these frequently co-occurring disabilities, the following definitions may apply. Students with co-occurring emotional/behavioral disabilities are described as displaying inappropriate, disruptive, aggressive behaviors that interfere with learning. Students with hearing loss and intellectual disabilities are characterized by a generalized delay in development across all areas of learning with limited problem-solving abilities and lowered adaptive or functional skills. Students diagnosed with learning disabilities and hearing loss are generally found to be in the average or above average range of intelligence displaying skills and abilities in many different ways while displaying specific learning deficits that restrict accomplishments. They are described as exhibiting unusual learning characteristics considered atypical of students who are deaf and hard of hearing in general; these greatly affect their progress. These students are not progressing academically in comparison to the documented parameters of delayed language and concept learning found in the general population of students who are deaf or hard of hearing (Bunch & Melnyk, 1989). In an effort to recognize this subgroup's uniqueness, the field appears to be moving away from using the label "learning-disabled hearing- impaired" and, instead, is beginning to label these students "deaf or hard of hearing with additional mild disabilities," "atypical learners with hearing loss," and "deaf or hard of hearing learners with additional learning problems."

How Are Additional Learning Problems Identified in Children Who Are Deaf or Hard of Hearing?

Identification of additional learning problems among children with diminished hearing is a difficult and complex task. Part of the difficulty arises from the fact that a hearing loss by itself creates pervasive learning problems that usually result in very delayed language acquisition and consequently delayed academic skills. Therefore, the identification of any other interfering or additional influencing factors affecting the students' learning can pose difficult issues. What difficulties come with the hearing loss and what difficulties are caused by another source or element? Furthermore, recognizing the additive effect of co-occurring disabilities, what unique learning profile is created by the combination of a hearing loss and the additional disability that are above and beyond any profile characterizing each individual disability alone?

Sound assessment practices using interdisciplinary teams are important when identifying additional disabilities in students who are deaf or hard of hearing (Paplinger & Sikora, 1990). This is particularly true when one considers that the characteristics displayed by students with co-occurring disabilities are often the same. A consistent lack of language learning, attention problems, retention difficulties, and delayed academic skills are phrases that are heard when professionals in the field describe students who have hearing losses and learning disabilities, intellectual disabilities, or emotional/behavioral problems. Therefore, differential diagnosis is critical to determining an accurate learning profile for the individual student, which includes a clear determination of the disabilities influencing that profile. The assessment should consist of teacher observations and appropriate standardized assessment measures as well as informal assessment procedures. Professionals involved should include school psychologists, classroom teachers, occupational and physical therapists, speech/language pathologists, audiologists, and any necessary medical personnel such as nurses, psychiatrists, etc. The team should provide careful interpretation of the assessment results with recommendations and suggestions for educational programming.

What Are Some Questions to Ask in Deciding Whether or Not to Refer My Child/student for an Evaluation?

Is the student who is deaf or hard of hearing progressing as would be expected when compared to his/her hearing impaired peers? This should be the first question when considering evaluation for a student with a hearing loss. Researchers (Kretschmer & Kretschmer, 1989; McAnally et al., 1994; and Yoshinaga-Itano, 1986) have documented parameters of delayed language acquisition and academic progress commonly seen in learners who are deaf or hard of hearing. Given the opportunities to learn language and academic skills through appropriate and efficient modes of communication, a learner with a hearing loss should progress in expected patterns of growth and achievement. If this is not happening, questions should be raised as to the reasons why.

Is the student with a hearing loss displaying any characteristics that are not usually seen with a hearing loss? Having a hearing loss brings with it many characteristics that affect the learning of the student. However, the hearing loss alone is not necessarily accompanied by such characteristics as visual-perceptual problems, attention deficits, perceptual-motor difficulties, severe inability to learn vocabulary and English structures, consistent retention and memory problems or consistent distractive behaviors or emotional factors. If any of these kinds of behaviors characterize the student who is deaf or hard of hearing, then an investigation into the possible influencing factors should be requested.

What Are Common Strategies Used to Help These Students?

It is very difficult to determine common strategies for students with additional learning problems primarily because each individual learning profile will be different depending on the number and nature of the various influencing factors. After some time spent looking for "fix-it" strategies, the professionals in this field appear to be moving toward the belief that all students with hearing losses should have individualized approaches to instruction, including those with additional learning problems (Powers, 1993). It is indeed a challenge to the professionals in the field to match the assessment learning profile with appropriate educational strategies to address the delineated problems. Generally speaking the following strategies may be useful. For those students with additional learning problems that include severe lack of vocabulary and simple syntax knowledge, work using pictures and picture symbols to support speech and/or signs has proven beneficial (Chalk, 1996). For those hard of hearing students who display characteristics more commonly associated with processing or understanding of sound, learning disabled students have benefitted from many of the aural/oral remediation techniques used to improve listening skills (Roth, 1991). Behavior techniques that include clearly defined choices and expectations with natural consequences have proven effective. Addressing emotional factors through the educational program and individual or group counseling when appropriate have also proven beneficial (Gage, et al, 1994; Rasing & Duker, 1993).

References and Additional Resources

Bunch, G. & Melnyk, T. (1989). A review of the evidence for a learning-disabled, hearing impaired sub-group. American Annals of the Deaf, 134, 297-300.

Chalk, P. (1996, Oct). New says of using communication symbols. Paper presented at the Fall LEA Workshop, Cave Spring, GA.

Craig, W.N. & Craig, H.B. (Eds.).(1993). Tabular summary of schools and classes in the U.S. American Annals of the Deaf, 138(2), 169-170.

Craig, W.N. & Craig, H.B. (Eds.). (1983). Tabular summary of schools and classes in the U.S. American Annals of the Deaf, 127(2), 188-189.

Craig, W.N. & Craig, H.B. (Eds.). (1973). Tabular summary of schools and classes in the U.S. American Annals of the Deaf, 118(2), 134-135.

Gage, S., Lou, M.W. & Charlson, E.S. (1994). A social learning program for deaf adolescents. Perspectives for Teachers of the Deaf, 13(2).

Kretschmer, R. & Kretschmer, L. (1989). Communication competence: Impact of the pragmatics revolution on education of hearing impaired children. Topics in Language Disorders, 9(4), 1-16.

McAnally, P.L., Rose, S. & Quigley, S.P. (1994). Language learning practices with the deaf. Boston: Little, Brown and Company.

Moores, D.F. (1987). Educating the deaf: Psychology, principles, practices.(3rd ed.). Boston: Houghton Mifflin.

Paplinger, D. & Sikora, D. (1990). Diagnosing a learning disability in a hearing impaired child. American Annals of the Deaf, 118, 480-487.

Powers, A. R. & Elliott, R. N. (Eds.). (1993). Deaf and hard of hearing students with mild additional disabilities. Monograph. Tuscaloosa, AL: The University of Alabama.

Rasing, E.J. & Duker, P.C. (1993). Acquisition and generalization of social behaviors in language-disabled deaf children. American Annals of the Deaf, 138(4), 362-369.

Roth, V. (1991). Students with learning disabilities and hearing impairment: Issues for the secondary and post-secondary teacher. Journal of Learning Disabilities, 24(7), 391-397.

Yoshinaga-Itano, C. & Downey, D. (1986). A hearing-impaired child's acquisition of schemata: Something is missing. Topics in Language Disorders, 7(1), 45-57.

For more information about the assessment process, see ERIC Digest E550 on assessment of students who are deaf and hard of hearing. For more information about services available in your state, contact your state's school for the deaf. A listing of these may be found annually in the April edition of the American Annals of the Deaf periodical.

Dr. Pollack is the educational diagnostician on the Diagnostic and Evaluation Team, Atlanta Area School for the Deaf.

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