Question from the field: Can early intervention pay for audiology evaluations and hearing aids? Approximately 50% of young children served by early intervention programs are eligible due to communication development concerns. Are early intervention programs responsible for providing audiology evaluations to children referred to Part C and have communication delay concerns?   Audiology Services – A 2003 letter to the Office of Special Education Programs said: “Your question focuses on infants and toddlers referred to Part C with delays in speech and language whose parents have not had their children’s hearing tested, sometimes because the family and/or physician feel that such testing is not warranted. Further, you state your agency’s belief that “the very fact that they have a speech delay means that further audiological testing is warranted to rule out any late-onset hearing loss.”… Specifically, you ask if an audiology evaluation is a required Part C service and whether the Part C lead agency is a payor of last resort for such services.” The answer is YES. Early intervention services include those designed to meet communication and physical development issues, including hearing loss. Audiology is identified as an example of early intervention services. Part C regulations require evaluation and assessment of the child’s functioning in a variety of domains and a statement of the present level of hearing status. Under Part C, an infant or toddler suspected of a communication delay whose hearing has not been tested and an audiology evaluation is needed must receive that evaluation as part of the overall early intervention evaluation process to be able to reflect the child’s present level of functioning. If audiology services are identified as a need on the IFSP, they must be provided at no cost by Part C if the child is not entitled to coverage for this service under any other Federal, State, local, or private source. Download this OSEP letter.   In many states the babies who fail newborn hearing screening and have been diagnosed with permanent hearing loss are referred to their local Part C early intervention program. Most of these infants require hearing aids and for some, use of DM Hearing Assistance Technology at home is appropriate. Are early intervention programs responsible for providing this assistive technology?   Hearing Devices – Another 2003 letter to the Office of Special Education Programs said: Under Part C, appropriate early intervention services must be available to all eligible children and families. Assistive technology devices and assistive technology services are listed among the identified early intervention services. Assistive technology devices are required only if they relate to the developmental needs of infants and toddlers served by the program. Linking the provision of those devices to an educational benefit is not appropriate under a program that serves children from birth to age three.  The “Secretary reiterates that the purpose of assistive technology devices is to meet the unique developmental needs of the child, as determined on an individualized basis through the IFSP development process.” The answer is YES. Hearing devices fit under the IDEA description of assistive technology as “any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of a child with a disability.” (20 U.S.C. 140(1)) Hearing devices are necessary to optimize the language development of children with hearing loss. Download this OSEP letter.   Click Here to Download this Article

Who are our babies with hearing loss? Fewer than 15% of the babies identified by Early Hearing Detection and Intervention (EHDI) programs have bilateral profound hearing loss (deaf) and more than 50% have mild bilateral or unilateral hearing loss. The distribution of degree of hearing loss in diagnosed infants is depicted in the following figure. Fewer than 1 in 20 newborns with congenital hearing loss have two parents who are hard of hearing or deaf. ¹ Therefore, most families of these children have little or no knowledge of hearing loss and its potential impact on language and speech development, social skills, and future academic and life success. The following information will share recent research findings about the needs of these children and available materials to assist early interventionists and families facilitate good early childhood development outcomes. The 2015 Outcomes of Children with Hearing Loss research² on children with permanent mild to severe hearing loss (25-75 dB) was a large-scale longitudinal study that followed children from six months of age to seven years old. There were 317 children who were hard of hearing and a comparison group of 117 children without hearing loss from 17 states. Almost all had permanent bilateral hearing loss and hearing aids. Three fourths were identified through newborn hearing screening. Assessment occurred every 6 months from age 6-24 months and annually thereafter to groups of children.   Summary of OCHL Findings: In general, this collection of articles has now proven what experienced early interventionists know – for children who are hard of hearing, hearing aids need to be well fit and worn consistently and families need to know how to communicate effectively with their child to maximally develop spoken language. The richness of the parent’s talk with the child influences the child’s language outcome. This ‘formula for success’ for children who are hard of hearing is now supported by strong research.² To accomplish these ends requires very knowledgeable interventionists who have the time to provide continued support to families throughout early childhood and the involvement of someone with expertise in the educational impact of hearing loss once the child is in school. The National Center for Hearing Assessment and Management (NCHAM) reports that detecting and treating hearing loss at birth for one child saves $400,000 in special education costs by the time that child graduates from high school.³ The amount saved can only be realized with the investment of early, appropriate services from experienced interventionists working to support families over time.   Early Intervention “Curriculums” There is no single resource that will impart all the knowledge needed to adequately support families of young children with hearing loss. The interventionist must have a sufficient background in hearing loss, understanding audibility/speech perception, language development, the continuum of communication choices, and adult learning – as a start. The following are resources that have materials that can be easily shared with families to enhance intervention. The best intervention is reactionary, in response to the current concerns of the family, that builds skills over time in relation to the child and family’s needs. That said, it is very helpful to have resources at hand to draw from as you respond to different family learning styles and needs. SKI*HI is perhaps the oldest and most recognized EI curriculum resource, especially for persons just starting to work with families of young children with hearing loss. The 2-volume, 2200-page resource includes information suitable to all degrees of hearing loss and exploration of and starting skill building in all communication choices. The visuals provided in the SKI*HI curriculum are something that interventionists use all the time!   EI Resources for Families Choosing to Use ASL Gallaudet has some informational webcasts that will be of benefit to early intervention providers assisting families in learning sign language to use with their young children. Refer to the list of EI webcasts, online learning resources and publications here. To learn any language, a child must be surrounded by fluent language users who dynamically involve the child in 2-way communication. Therefore, teachers of the deaf/hard of hearing who are highly skilled in the use of sign language and/or adults who have hearing loss and use sign language (Deaf Role Models) are the optimal choice for facilitating the family’s effective use of sign language. Referencing sign language dictionaries such as Signing Fun, the Gallaudet Children’s Dictionary, and ASL Basics for Hearing Parents of Deaf Children is often very useful to families. It is important for EI providers to understand the developmental hierarchy for learning sign language. ASL developmental hierarchy information can be found at the end of this White Paper.   EI Resources for Families Choosing to Use Listening and Spoken Language Listen Little Star is a tried and true resource from Australia that has 12 lessons for the family of infants (0-12 months). It is easy to use and has a DVD with professional grade video clips to accompany each lesson. The Learn To Talk Around The Clock Toolbox is organized around a set of principles and provides hundreds of suggestions for natural practice in the family’s home or child care setting in an orderly presentation of skills known as “Signature Behaviors.” Author Karen Rossi, DHH teacher and LSLS, has an incredibly helpful website to support families, early interventionists, childcare and into preschool. The Language Development Knowledge Cards have many applications. The Listening Room (Advanced Bionics AB4Kids) features three sections with content created specifically for age groups: Infants & Toddlers, Kids, Teens & Adults. Register to be able to see and download free activities and resources to support the development of speech, language, and listening skills. AB4Kids also offers the Baby Beats (video) app to develop listening and communication skills in young children. They also provide wonderful resources for preschool and school-aged children. Cochlear Corporation has provided extensive, incredible resources with Sound Foundation for Babies and Sound Foundation for Toddlers. Designed for 12 months and up, the skills for babies start at a beginning auditory awareness level are applicable to children who are hard of hearing identified in the first few months along with those who are recently implanted. Babies Babble, Toddlers Talk, and Children Chatter are all videos that support the Listen, Learn, and Talk book. The Cochlear suite of materials is helpful to any interventionist or teacher working with children with useable residual hearing. There are also resource for parents of school-age children and could selectively provide some basic information for teachers. It is great to have this bank of resources videos at your fingertips. MED-EL cochlear implant company also provides resources to purchase that will support listening and communication development.  Their free offerings include Ling Cards (set of 7 cards, 3” x 5”), Little Listeners comprehensive guide for preverbal speech, language and auditory development, Little Listeners in Spanish and other resources that can be ordered for free, or downloaded as PDFs.   Early Intervention Materials Early Language Development Handouts and Activities with Bonus CD  This inexpensive resource provides 25 informational and activity-based handouts that will help you tell parents and caregivers at home how they can stimulate language development in their young ones. Copy the black and white handouts or print color versions from the CD. Early Intervention Kit – Teaching Guide, Activities Book, Sign Language Cards While this is not a DHH-specific resource, this kit has the essential information and tools for successful early intervention services. Effectively address assessment, intervention, and documentation. The Activities Book is a gold mine of intervention objectives, goals, and specific suggested activities, for Pre-Linguistic Skills, Expressive Language Skills, Receptive Language Skills and Sound Production Development.  Listen Little Star is for families of infants newly diagnosed with hearing loss. It is excellent for families to obtain and use independently as a supplement to their early services. It is even more effective when used as a family-friendly guide to early intervention whether used by a provider with limited background in DHH or a veteran early intervention DHH teacher. This colorful 160+ page guide is divided into 12 lessons and also includes an extensive Baby Response Checklist data gathering tool and other resource materials at the end. A DVD with professionally recorded video lessons provides a description and video showing the lesson being done by a parent and child. It is an excellent way to teach the skill in the printed or digital guide. Achieving Effective Hearing Aid Use in Early Childhood The purpose of this guide is to further the understanding of children’s development, how developmental stages will affect hearing aid wear, and what families and early intervention teachers can do to achieve full-time hearing aid wear. By using the information in this guide, hearing aid retention accessories and specific age-appropriate strategies, it is hoped that families will be better prepared to manage their child’s hearing aid wear. The guide is 88 pages long and is available in digital or paper versions. Information written in this guide is directed toward parents, which makes it ideal to use as an intervention guide while providing services to families of infants, toddlers and transitioning preschoolers. The Developing Child with Unilateral Hearing Loss 20%-30% of all infants diagnosed with hearing loss have unilateral hearing loss (UHL). The result is hundreds of families of babies with unilateral hearing loss who are seeking assistance to understand what the hearing loss may mean to their child’s future and to receive direction on how they can best influence their child’s success. The publication is a step-by-step guide to early intervention for children with UHL. It is available in digital and paper versions. The early intervention material is based on a 100-slide PowerPoint Presentation that explains what should be discussed at each of the first 5+ early intervention sessions along with family-friendly information to address each key point. Handouts have been drawn from the slide groups to serve as a summary of key concepts. Social-Emotional Evaluation/Assessment Measure (SEAM) The SEAM is an in-depth, easy-to-use tool, to reliably assess and monitor social-emotional development in infants, toddlers, and preschoolers at risk for delays or challenges. The two-part SEAM™ assessment reveals detailed qualitative information on children’s social-emotional competence – and identifies their caregivers’ strengths and areas of need. Easy to learn and implement, SEAM can be used by a wide variety of early childhood professionals, including those with little or no training in mental-health or behavioral interventions.   APPS! There are literally thousands of apps available, with varying quality and effectiveness. Without any recommendations, the following are some resources regarding apps for babies/young children with hearing loss:   References Click Here to Download the Full Article

Question from the field: We keep going around and around in the IEP process, not agreeing. What are our options? We have had 4 amendment meetings since our daughter’s last IEP meeting. We are not in agreement, and at every meeting we seem to be going in circles. We have heard about due process, but don’t want the district to be mad at us. What happens in due process? While the idea of due process or taking legal action can be scary for many families, and is not what anyone, either the family or the district wants, it can often have very positive results for the child, the family, and the district. If the team is continuing to have IEP meetings and getting no further in the process, then taking the conversation to the administration outside of the IEP meeting can lead to open, honest, and productive discussions. Having multiple IEP amendment meetings to discuss the same requests, concerns, or disagreements can create frustration and ill will all around. When families feel that they are not being heard or that their child’s needs are not being addressed, it can lead to resentment and mistrust of the educators. When DHH Specialists and other district members of the IEP team, who are not administrators or decision makers, are put in the difficult position of defending an offer it can also lead to damaged relationships with the family. Once a family takes their requests to the next level of decision makers and opens the door to additional discussion, it provides an opportunity for some very productive conversations to take place. While this is in no way a comprehensive guide, following are the basic stepping stones in due process. Prior to filing a request for due process, the district administrator may reach out to the family for an alternative dispute resolution (ADR) meeting. Parents may also choose to reach out to the district in an effort to explore if there is a willingness to meet outside of the IEP. All parties should be sure to not approach this meeting as an IEP meeting. It is not. This is an opportunity to think outside of the box in an effort to find a solution and to recognize that the family and district have many years to work together. I would advise parents to remember this and really advocate for alternative ideas, and to not have this meeting turn into another frustrating IEP-like meeting. While different states may have some additions or differences in the timelines, what follows is a basic timeline of what to expect per IDEA requirements once a family files a request for due process:

1. Following receipt of the request for due process, the school district has 15 days to offer the family an Informal Dispute Resolution (IDR) meeting.¹ The IDR can be waived only if both the family and the district agree to waive the meeting. I would recommend attending IDR. It is a wonderful opportunity to explore misunderstandings, clarify what is being requested, and work with the decision makers to resolve the disagreements that have arisen from the IEP meetings. This is a meeting that typically will not include attorneys for either the family or the district. Because this is the first opportunity to speak candidly as well as confidentially, it can be quite beneficial for families of children with hearing loss. If this meeting begins to feel like another IEP meeting, it can be ended at any time.

2. The State Department of Education will set dates for both the mediation, which is completely voluntary and confidential,² and the hearing. A judge or mediator and representatives for the family and district voluntarily attend. For the mediation meeting the job of the judge is to facilitate a compromise. Surprisingly, while the unknown aspects of this process are understandably stressful for families, mediation can be the experience that repairs the relationship. This is not a promise, but a true possibility. As such, it is a wonderful opportunity for families of children who have hearing loss. There are so many unique and different needs regarding students with all degrees of hearing loss and all modes of communication that administrators do not always understand the nuances. Because hearing loss is a low incidence disability, many of these administrators have relied on regionalized programs or Non-Public schools to educate their students. These administrators may honestly be unaware, until the mediation, what the student needs are or that parents have options regarding mode of communication and language development. Administrators may not realize that students with hearing loss have the right to “opportunities for direct communications with peers and professional personnel in the child’s language and communication mode, academic level, and full range of needs including opportunities for direct instruction in the child’s language and communication mode.”³ In my experience supporting families and districts, as long as both parties are willing to participate in mediation, the strained relationships can begin to heal during mediation. In 2018 approximately 83% of cases were resolved in mediation in Minnesota⁴ and 97% of cases were resolved at, or just following mediation, in California.⁵

3. Should the case go to hearing, following a due process decision the family and district have 90 days to file an appeal.

  The special education system can be overwhelming for families as it has a language all its own. Families do not need to enter any of these steps alone. Consulting with either a special education attorney or an advocate to prepare and navigate the process can be beneficial. Someone who not only understands special education law, but also understands the unique needs of children with hearing loss has the potential to facilitate getting appropriate placement and services, help to the repair of the relationship, and provide additional education for the district administrators. Just as the path of due process may feel intuitively adversarial, it may also feel adversarial to think about bringing an attorney or advocate. However, again, this can actually take the stress off of the family and provide the path to ending the cycle of IEP meetings and amendments that seem to be going nowhere.  

1. 1. IDEA [20 USC 1415 (f)(1)(B); 34 CFR 300.510]; Preparing for Special Education Mediation and Resolution Sessions: A Guide for Families and Advocates
2. 2. IDEA [20 U.S.C. 1415(e); 34 CFR 300.506]; Preparing for Special Education Mediation and Resolution Sessions: A Guide for Families and Advocates
3. 3. IDEA section 300.324(2)(iv)
4. 4. ldonline.org/article/6302/
5. 5. amsterlawfirm.com/blog/what-happens-after-you-file-for-due-process

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A recent US court case¹ made it clear that students with hearing loss must receive an eligibility assessment that identifies areas of suspected need secondary to hearing loss must be evaluated with sufficient intensity to satisfy in depth evaluation. The special factors considerations² also needs to be applied throughout the evaluation process. Furthermore, the LEAD-K³ movement has spotlighted the need for appropriate, tailored assessment of children who are deaf or hard of hearing.  The big question from the field of education for children with hearing loss is ‘What assessments should we be using?’ 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. While academic performance needs to be considered, it is no more important to consider than the other areas specified by IDEA which are functional, behavioral, social needs 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 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. Even ‘good’ students with hearing loss can qualify IF there is someone on the multidisciplinary team who truly understands the impact of hearing loss on development AND uses appropriate assessments to use to tailor the evaluation process to the risk areas of students with hearing loss. Teachers of the deaf/hard of hearing and educational audiologists should have/receive the training needed to feel comfortable in assessment. The defined purpose of IDEA⁴: 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. Performance of the expanded core skills needed for full participation (self-advocacy, communication repair, knowledge about hearing loss, amplification independence, etc.) are 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. LIST OF RECOMMENDED ASSESSMENTS: The list includes recommendations for both functional and formal assessments for ages 3-5 years and school-age students. 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 comprehension and reading fluency.

Download an updated version of Resources for Identifying DHH Student Needs: Eligibility Assessment and Beyond that reflects some of the information discussed in Steps to Assessment and additional recent tests not included in that book.

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. A study⁵ found that 40% of students with hearing loss have a capacity for higher language levels beyond what test scores indicate. Further⁶, language learning for students with hearing loss occurs on average at 70%, or just above 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 Study⁷ was 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. Although 80%⁸ 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. Language, social, and reading delays occur secondary to lifelong decreased access to communication. EVERY student with hearing loss who is going through initial assessment needs to have IQ testing 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.⁹ Students with hearing loss (DHH-only) experience delays secondary to access issues. 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.

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.

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 5^th 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 48^th percentile in reading as compared to the 26^th 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. 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. 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.   References

1. Ninth Circuit Court of Appeals, June 1, 2018, S.P. v. East Whittier City School District: https://successforkidswithhearingloss. com/wp-content/uploads/2019/01/Court-case-RE-need-for-thorough-assessment-highlighted.pdf 2. IDEA section 300.324(2)(iv): Consider the communication needs of the child, and in the case of a child who is deaf or hard of hearing, consider the child’s language and communication needs, opportunities for direct communications with peers and professional personnel in the child’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the child’s language and communication mode. 3. LEAD-K: Language Equality and Acquisition for Deaf Kids. https://successforkidswithhearingloss.com/wp-content/uploads/2019/01/Court-case-RE-need-for-thorough-assessment-highlighted.pdf 4. The 2004 IDEA Commentary provides an overall ‘setting the stage’ for the IDEA law; on this webpage. 5. 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. Results² focused on children with hearing loss who have language levels within the average range on standardized measures. 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. 6. 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. 7. Epilogue: Conclusions and Implications for Research and Practice. Ear and Hearing, 36, 92S-98S. Sole reliance on norm-referenced scores may overestimate the outcomes ofCHH. When the children who are hard of hearing (CHH) were compared with the norm-referenced group on various measures, the differences were small. However, when compared the CHH to a 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 question the sole reliance on comparison to norm-referenced test scores for judging eligibility. Standardized test scores may overestimate CHH as they are unlikely to reflect the level of effort that students are expending (cognitive and perceptual resources) to maintain competitiveness with peers in secondary schooling, where the cognitive demands increase. We need to closely monitor the outcomes of CHH including comparing their performance relative to neighborhood grade-mates. Many CHH in the OCHL study represent the best-case scenario. We might expect that a sample with greater diversity on these dimensions would not perform as well as the OCHL cohort 8. 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. Due to 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.9. Addressing the Need for Appropriate Use of Norm-Referenced Test Instruments. Supporting Success, December 2017.

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