The great news is that early identification of hearing loss, improvements in hearing technology, and parent involvement in high quality early intervention services REALLY WORK to improve developmental outcomes by age three. This all too often results in transition teams who are evaluating the student for eligibility upon school age to deem that the student is ‘fine’ and needs no extra services or supports.
Can he qualify? Yes! This is possible IF there is someone on the multidisciplinary team who truly understands the impact of hearing loss on development AND knows appropriate assessments to use to tailor the evaluation process to the risk areas of students with hearing loss.
The IDEA law is consistent about looking at educational performance needs when considering a student’s eligibility for specialized instruction and support. Educational performance is not equivalent to academic performance. If the creators of IDEA wanted to make it clear that good grades = no IEP they would have clearly done so – but they did not. There is no question that academic performance needs to be considered, but it is no more important to consider than the other areas specified by IDEA which are functional, behavioral, social performance and any other performance considerations relevant to the specific child. If a school team only considers grades for eligibility then they are using a sole criterion, which goes against the IDEA requirement that eligibility determinations be made using academic, functional, and developmental information with consideration of at-risk areas as determined by the suspected area of disability.
Our students with hearing loss may ‘look fine’ in the classroom yet we realize that there are usually subtle differences/needs that, added together, cause academic performance to erode over time. Thus, in evaluations, it is appropriate to look closely at social/emotional, self-advocacy, and the possibly subtle phonological/morphological awareness and ‘swiss cheese’ language skills that impact reading fluency and comprehension. It comes down to: “Will this student develop the skills he or she needs to truly be able to successfully get a job or enter higher education after high school?” Download Resources for Identifying DHH Student Needs: Eligibility Assessment and Beyond that reflects some of the information discussed in Steps to Assessment. Discussion of the impact of hearing loss on these different eligibility areas, including assessment, will be the topic of future Updates.
Low average language results reflect the impact of hearing loss, not capability. So often for our students, qualification for specialized instructional services hinges on the results of language assessment as that is the most highly recognized area of deficit secondary to hearing loss. Ideally, hearing aid fitting for children who are hard of hearing would be completed no later than 3 months of age, but this is not the norm for most students with hearing loss. Delays in amplification fitting, and inconsistent use of hearing aids until school age is more the norm in many places. One study1 found that each month lag in amplification fitting attributes to 0.17 months in receptive and 0.30 months in expressive language. Additionally, each 10 dB of hearing loss accounts for an average of 5+ months of delay in receptive and expressive language. A very recent study2 found that 40% of students with hearing loss have a capacity for higher language levels beyond what test scores indicate. Further3, language learning for students with hearing loss occurs on average at 70%, or about 2/3, of the rate of children with normal hearing.
It is appropriate to anticipate that most children with hearing loss upon school entry will have some delay in expressive and/or receptive language, with greater degrees of hearing loss predicting greater levels of language delay. Also, the nature of hearing loss causes incidental language to be missed whenever a child is further away from about 3-6 feet of the speaker. This typically results in ‘spotty’ or ‘Swiss cheese’ language rather than solid overarching language delays. A student may therefore score higher than his or her actual functional language ability, based on the actual questions asked during the assessment and the individual’s particular vocabulary or conceptual knowledge. One strong finding from the robust 2015 Outcomes of Children with Hearing Loss Study4 was that when children who are hard of hearing are compared specifically to others their same age and socioeconomic status, the size of the effect of hearing loss on language averages 2/3 of a standard deviation. The study concluded that normative test scores overestimate the abilities of children who are hard of hearing as they are unlikely to reflect the level of effort that students are expending to maintain competitiveness with peers. In regard to the language development of children who are audiometrically deaf, 96%5 are currently born to hearing parents with no fluency in visual communication that would readily create an environment of rich visual language learning in early childhood. Although 80%5 of children born deaf in the developed world receive cochlear implants, the success rate with cochlear implants is highly variable and cannot be assumed to ever ‘fix’ all language development issues, even for children with the best outcomes. We must consistently communicate with our school teams that students with hearing loss are not language disordered. Delays occur secondary to lifelong access to communication issues.
It is important for DHH professionals to share with school teams the finding that at least 40% of students with hearing loss have a capacity for higher language levels beyond what test scores indicate. With this in mind, it is critical for DHH professionals to make the case that EVERY student with hearing loss who is going through initial assessment needs to have IQ testing. It is likely not that we think the student has low in cognitive skills. We need the IQ in order to accurately and appropriately estimate if/how much the hearing loss has impacted development based on the student’s ability compared to peers who do not have hearing loss. Students with hearing loss (DHH-only) experience delays secondary to access issues. Title II of the American’s with Disabilities Act requires that schools ensure that communication for students who are deaf and hard of hearing “are as effective as communication for others through the provision of appropriate aids and services, thus affording an equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement as that provided to others. It is important to know the cognitive ability of each student with hearing loss as their communication access needs must be accommodated so that they reach the same level of achievement as their cognitive peers.
Although testing is performed in a few weeks’ time, evaluation isn’t just about a snap shot, it is about performance over time. Case in point, we received a call from a parent of a 5th grader who is hard of hearing. The child had an IEP in kindergarten and grade 1 and was then dismissed. By the end of grade 4 the reading scores had decreased. The school team wasn’t concerned because the student ‘wasn’t very bad yet.’ Time should be taken to consider the percentile scores on reading across time to see if there has been a decline. When looking at eligibility, dig into prior testing and see if you can make the case with declining percentile ranking in test results over time. For example, in grade 2 did the child score at the 48th percentile in reading as compared to the 26th percentile in grade 4? A public agency must provide a child with a disability special education and related services to enable him or her to progress in the general curriculum. The fact that there is a decline indicates that there are special needs that have not been addressed for the student. Access needs and/or deficits in specific skills foundational to reading comprehension would then need to be identified.
Finally, we need to step back and consider the 2004 IDEA Commentary. The Commentary provides an overall ‘setting the stage’ for the IDEA law. Section by section the Commentary responds to the comments submitted during the 2004 reauthorization process and provides explanations. The commentary is broken into sections on this webpage. The defined purpose of IDEA: To ensure that all children with disabilities have available to them a free and appropriate education that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment and independent living. Therefore, the purpose of IDEA is not to support students so that they can make progress commensurate with age/grade expectations. IDEA services were envisioned as being about preparation for the future. Thus, performance on the expanded core skills needed for full participation (self-advocacy, communication repair, knowledge about hearing loss, amplification independence, etc.) are truly necessary for a student to be fully prepared to function as an adult. These are NOT standard areas of evaluation for other students with special needs but they must be considered as part of a tailored assessment for students who are deaf or hard of hearing.
Sometimes administrators make the point that schools must provide educational benefit for students but do not have to guarantee that the student reaches his or her potential. While this was established by a court cast (Bd. Ed. Hendrick Hudson Sch. Dist v. Amy Rowley, 1982), Commentary from the 2004 reauthorization specific to preparation for the future needs and the relationship of expanded core skills for the future success of students with hearing loss needs to be taken into account when ‘educational benefit’ is determined. Indeed, per the March 2017 decision of the US Supreme Court, schools may not settle for minimal educational progress by disabled students. Educational programs must be reasonably calculated to enable a child to make progress appropriate in light of the child’s circumstances. In the case of students with hearing loss, the expectation would be to provide full access to school communication and specialized instruction to fill in learning gaps PLUS support typical/expected levels of progress in the classroom. Therefore, evaluation must be tailored to identify the access, learning, and functional performance needs of every student with hearing loss so that they can progress equal to their cognitive peers.
1. Auditory development in early amplified children: Factors influencing auditory-based communication outcomes in children with hearing loss. Ear and Hearing, 31(2), 166-185
Another 2010 study1 looked at the level of hearing loss and age of amplification fitting impact on language development. Each 10 dB of hearing loss accounted for 5. 9 months decrease in receptive language performance and 5.2 months of performance lag in expressive language performance. Age at fitting was predictive of both language measures with each month of lag in amplification fitting attributing to a language lag of 0.17 months in receptive and 0.30 months in expressive language. Not surprisingly, children with the earliest access to the speech signal through amplification have the best outcomes on auditory-based communication measures. Holding the age at fitting or degree of hearing loss constant, children using a cochlear implant can expect an improvement of 12 months in receptive language and 18 months in expressive language.
2. Language underperformance in young children who are deaf or hard-of-hearing: are the expectations too low? Journal of Developmental & Behavioral Pediatrics. September 19, 2017.
Research released at the end of this September2 shared results focused on children with hearing loss who have language levels within the average range on standardized measures. The researchers identified a mismatch between the cognitive level children test at and the expectations for their language skills. In examining the abilities of their 152 young child subjects they found that at least 40 percent have a capacity for higher language levels – beyond what their language test scores indicate.
3. The Effect of IQ on spoken language and speech perception development in children with impaired hearing. Cochlear Implants International, (11)1, June, 370-74.
A 2010 study3 found that children were learning language at approximately 2/3 of the rate (or 70% of the rate) of their normally hearing peers. Subjects were 62 children ages 5-12 years who used oral communication and attended oral early intervention or school settings. Children in preschool learned language at a faster rate than children attending primary school. On average, children attending preschool were learning at 0.78 of the rate for normal hearing children as compared to a rate of 0.67 for students in primary school. Speech perception scores did not plateau until children had, on average, the language ability of a typically hearing 7-year-old.
4. Epilogue: Conclusions and Implications for Research and Practice. Ear and Hearing, 36, 92S-98S.
Sole reliance on norm-referenced scores may overestimate the outcomes of CHH. The findings from this study provide consistent evidence that limitations in hearing sensitivity have an impact on children’s development of language. It could be argued, however, that this effect is not sufficient to lead to a disabling condition for the majority of these children. When the CHH are compared with the norm-referenced group on various measures, the differences are small. However, when we compared the CHH to our sample of CNH who were matched on age and SES, the size of the effect of HL on language doubled to two thirds of a standard deviation. These results lead us to question the sole reliance on comparison to norm-referenced test scores for judging the adequacy of the developmental outcomes of CHH. It is likely that CHH will compete in school settings with children from similar home backgrounds, who may serve as a more realistic comparison group. Furthermore, an anonymous reviewer pointed out another way that test scores may overestimate CHH: standardized tests scores are unlikely to reflect the level of effort that students are expending (cognitive and perceptual resources) to maintain competitiveness with peers in secondary and postsecondary schooling, where the cognitive demands increase. This suggests a need to closely monitor the outcomes of CHH including comparing their performance relative to neighborhood grade-mates.In interpreting this study, it should be kept in mind that many CHH in the OCHL study represent the best case scenario; their caregivers are fairly well resourced and most had the advantage of early access to interventions. We might expect that a sample with greater diversity on these dimensions would not perform as well as the OCHL cohort.
5. Language acquisition for deaf children: Reducing the harms of zero tolerance to the use of alternative approaches. Harm Reduction Journal, 2012, 9-16.
Today, 80% of children born deaf in the developed world are implanted with cochlear devices that allow some of them access to sound in their early years, which helps them to develop speech. However, because of brain plasticity changes during early childhood, children who have not acquired a first language in the early years might never be completely fluent in any language. If they miss this critical period for exposure to a natural language, their subsequent development of the cognitive activities that rely on a solid first language might be underdeveloped, such as literacy, memory organization, and number manipulation. An alternative to speech-exclusive approaches to language acquisition exists in the use of sign languages such as American Sign Language (ASL), where acquiring a sign language is subject to the same time constraints of spoken language development. The success rate with cochlear implants is highly variable due to a variety of child, family, device function, and habilitation treatment variables. The vast majority of deaf infants (approximately 96%) are born to hearing parents, who often know very little about sign language or Deaf communities. These parents are in a state of vulnerability, grieving the loss of a normally hearing child and fearing what the future may hold (or not hold) if their child cannot speak like a hearing child. They might view sign as an inferior choice or a last resort and not fully understand that sign language is a human language with the linguistic complexity and expressiveness of spoken language. They might also fear their child will be stigmatized if they use a sign language. Furthermore, they might be afraid of trying to learn a new language at their age. In the absence of relevant information, many parents opt for the speech-only route because, without appropriate advice and information, they do not understand the risks of linguistic deprivation.
Karen L. Anderson, PhD, Director, Supporting Success for Children with Hearing Loss; Late October Update. This information is not intended as legal advice. http://successforkidswithhearingloss.com Sign up to receive Bimonthly Updates from Supporting Success.