DEGREES OF DEAFNESS: FROM DISCOVERY TO EDUCATION

© 1998 Renee M. Newman

R. M. Newman Communications

Henderson, Michigan USA

Author e-mail: reneenew@shianet.org

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When parents first suspect that their infant is not hearing, they should record the evidence in a journal and present it to the pediatrician. The pediatrician will investigate further and refer the child to an ear-nose-throat specialist (otolaryngologist), who will review the evidence presented by parents, examine the structures of the outer and middle ear, and use special equipment to test hearing or will refer the child to an audiologist (Schwartz 1996, xvi-xix).

In the testing facility, the audiologist will take the child's history. The child will relax in a soundproof room and be tested for response to an audiometer, which produces various tones and volumes. If ear phones are tolerated, each ear is tested independently. The child is tested for response to familiar speech. If audiometer testing is unsuccessful, a Brainstem Evoked Response test is administered (Schwartz 1996, xvi-xix).

If hearing loss is confirmed, another appointment with the audiologist is required for the fitting of hearing aids. In the mean time, parents are directed to contact their local school district for information regarding educational services for the deaf. National organizations for the deaf can also provide information on local programs (Schwartz 1996, xx).

Hearing aids amplify sound but cannot make it clearer, and cannot restore perfect hearing. The goals of amplification are to make speech audible and to maximize residual hearing. Dual hearing aids provide better sound localization, better focus on sound with background noise, a reduced need for amplification in each ear, and more natural sound quality (Schwartz 1996, 33).

All amplification systems pick up sound through a microphone and send it to an amplifier (which increases loudness), then to a speaker which delivers the sound to the ear through a device like an earmold or hearing aid. There are three main types: conventional personal hearing aids, (2) FM systems, and (3) newer technological alternatives (Schwartz 1996, 33-34).

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There are three types of conventional hearing aids denoted by position: (1) behind the ear (BTE), (2) in the ear (ITE), and (3) in the canal (ITC). BTE devices are used for moderate to severe hearing losses and require an earmold and sometimes a "huggy" to keep them firmly in place. Some are equipped with direct audio input for use with auditory trainers. When the child's ear growth has stabilized and if the child has sufficient residual hearing, ITE and ITC hearing aids can be molded to fit inside the ear (Schwartz 1996, 34).

There are two FM system types: traditional FM auditory trainers and FM hearing aids. FM systems involve a microphone and transmitter worn by the teacher or other speaker and a receiver worn by the child. Voice clarity and volume are not diminished by distance, as FM signals reach several hundred feet. The receiver, the size of a cigarette pack, is worn on a belt, and is wired to the hearing aid. Auditory trainers produce consistent sound because sound first passes through the hearing aid before reaching the ears. A heavier BTE, FM hearing aids contain a small receiver and are worn behind the ear, eliminating cords but still resulting in consistent sound (Schwartz 1996, 36).

New technology has facilitated the presentation of sound in new and targeted ways. These devices include transposers, programmable personal hearing aids, and cochlear implants. Transposers transform inaudible high pitched sounds (like /s/, /sh/, /f/) into audible low pitched sounds. For older children, hearing aids can be programmed by a computer to amplify soft sounds and sounds of different loudness according to individual needs.

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When no benefits are gained from other hearing aids, cochlear (middle ear) implants are considered (Schwartz 1996, 36-37).

Cochlear implants replace the damaged hair cells of the inner ear. A microphone in the unit picks up environmental sound sending it by wire to the speech processor that converts it to electronic code. The code is sent by wire to a transmitter that sends the signal across skin to the receiver/stimulator which converts the code into electronic signals that are sent to tiny electrodes inserted in the cochlea. The electrodes stimulate nerve fibers in the auditory nerve which carry messages to the brain that are interpreted as sound (Schwartz 1996, 37).

There are several types and causes of hearing impairments. A problem with the outer or middle ear can interfere with sound conduction and is called a conductive hearing impairment. A CHI may be partially or fully corrected with surgery and or medication, and may be improved with amplification devices and hearing aids (The Hearing Center 1998).

A hearing impairment based in the inner ear is considered a sensorineural hearing impairment. It is usually the result of damage or degeneration of tiny nerve endings, and amplification is typically the only corrective procedure (The Hearing Center 1998).

When conductive and sensorineural hearing impairments coexist, the resulting condition is termed a mixed hearing impairment (The Hearing Center 1998).

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When a family is told that their child is deaf or hearing impaired, they are overwhelmed with difficult communication decisions. A variety of professionals step up to offer different options and approaches. Usually families give in to professional advice and delegate important life long decisions to these experts. But families are cautioned to take time to research their options (Dedert 1998).

Families must realize that there are no best and sure options for every child. The family must put its interests first, and weigh the alternatives against its values, beliefs, goals, resources, abilities, and comfort level. Any methodology will require family involvement, commitment and careful monitoring. The greatest determinants to success are love, patience and understanding. Families should know that much controversy surrounds the predominant communication modes. The only defense is an accurate understanding of each option gained through thorough research (Dedert 1998).

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It is helpful to consider options from the standpoint of a family's legal rights. Meeting the definition of "disability," deafness is an impairment that inhibits a major life activity (communication and learning) and is therefore covered by Section 504 of the Civil Rights Act. Section 504 requires that schools provide a "504 plan" that serves to eliminate disability-based school discrimination. Appropriate accommodations must be made for the deaf child so that he can participate in and benefit from regular public education and activities.

Another controlling law is the Individuals with Disabilities Education Act Amendments of 1997, Public Law 105-17, also known as IDEA '97. IDEA '97 spells out the procedures and programming that must be provided to children and youth with disabilities in order for States to receive Federal funds. It has six main principles: (1) Free Appropriate Public Education (FAPE), (2) Appropriate Evaluation (AE), (3) Individualized Education Program (IEP), (4) Least Restrictive Environment (LRE), (5) Parent and Student Participation in Decision Making (PSPD), and Procedural Safeguards (NICHCY 1998).

The term 'free appropriate public education' means special education and related services that--"(A) have been provided at public expense, under public supervision and direction, and without charge; (B) meet the standards of the State educational agency; (C) include an appropriate preschool, elementary, or secondary school education in the State involved; and (D) are provided in conformity with the individualized education program required under section 614(d)." [Section 602(8)].

"'At no cost' means that all specially designed instruction is provided without charge, but does not preclude incidental fees that are normally charged to nondisabled students or their parents as a part of the regular education program. (34 CFR §300.17) " Each child with a disability is entitled to a planned education (IEP) that is "appropriate" for his or her needs, based on the findings of appropriate evaluations.

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Children with disabilities have the right to attend public school just as other children do, regardless of the nature or severity of their disabilities. The schools must provide the six principles and future life or transition planning [34 CFR §300.8].

Appropriate Evaluation means the use of evaluation procedures that assure all children with disabilities are appropriately assessed with measures that are not racially or culturally discriminatory for the purposes of eligibility determination, educational programming, and individual performance monitoring. "The committee believes that a child should not be subjected to unnecessary tests and assessments... and the LEA should not be saddled with associated expenses unnecessarily (Committee on Labor and Human Resources 1997, 19)."

Evaluation activities should include gathering information related to enabling the child to participate and progress in the general curriculum and appropriate activities. Evaluators must be knowledgeable and trained in the use of their tests and other evaluation materials, and a variety of instruments and procedures must be used to gather relevant functional and developmental information (NICHCY 1998).

The Individualized Education Program ensures that education is appropriate and customized. The IEP is a statement that is written and revised in compliance Section 614(d). The IEP contains (1) the child's present levels of educational performance, including how the child's disability affects his or her involvement and progress in the general curriculum; (2) measurable annual goals, including benchmarks or short-term objectives;

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(3) the special education and related services, and supplementary aids and services, to be provided to, or on behalf of, the child; (4) the program modifications or supports for school personnel that will be provided for the child to advance appropriately toward meeting annual goals and to participate and progress in the general curriculum and other nonacademic activities; (5) an explanation of the extent, to which the child will not participate with nondisabled students in the regular class and in extracurricular activities; (6) statements of any individual modifications in the administration of State and district-wide assessments of student achievement, including details of alternative assessments; (7) the projected date for the beginning of services and modifications, and the anticipated frequency, location, and duration of services and modifications; (8) beginning at age 14, a statement of annual transition services needed; (9) a statement of legal rights one year before the state age of majority that will transfer to the child upon reaching majority; (10) and the details of progress reporting which must include measurements of progress toward annual goals, and schedules and forms of regular reporting to parents [Section 614(d)(1)(A)].

The IEP is created by an informed team of the following individuals: (1) parents or child's legal guardian; (2) at least one of the child's regular education teachers; (3) at least one of the child's special education teachers or special education service providers; (4) a representative of the local educational agency who is (i) qualified to provide or supervise the provision of specially designed instruction to meet the unique needs of children with disabilities and (ii) knowledgeable about the general curriculum and (iii) knowledgeable about the availability of the LEA's resources; (5) an individual capable of discerning the instructional implications of evaluation results; and (6) other individuals with relevant knowledge or special expertise including related services personnel, and the child, whenever appropriate [Section 614(d)(1)(B)].

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The IEP lists the services that the school will provide to, or on behalf of, the student. The IEP is reviewed and rewritten annually, however, it can be revised at any time, if the child is not making expected progress or if new variables arise.

The IDEA guarantees each child with a disability a "free appropriate education in the least restrictive environment." LRE is: ". . . the presumption that children with disabilities are most appropriately educated with their nondisabled peers and that special classes, separate schooling, or other removal of children with disabilities from the regular educational environment occurs only when the nature or severity of the disability of a child is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily [Section 612(a)(5)(A)]."

Under IDEA 97, "appropriate aids and supports" are referred to as "supplementary aids and services." This memo made it clear that a student's placement in the general education classroom is the first option the IEP Team must consider. The IEPC (Individualized Education Planning Committee) must consider the full range of supplementary aids and services needed to ensure that the student can be satisfactorily educated in the regular classroom. The IEPC placement determination is "the LRE for that student (Heumann 1994, 2)."

If the IEPC determines that the student cannot be educated satisfactorily in the general education classroom, even with supplementary aids and services, alternative placement is considered. Schools still are required by law to ensure that "a continuum of alternative placements is available to meet the needs of children with disabilities for special education and related services [34 CFR §300.551(a)]."

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This continuum includes a range of alternative placements such as "instruction in regular classes, special classes, special schools, home instruction, and instruction in hospitals and institutions (Committee on Labor and Human Resources 1997, 11)."

In the first few pages of the IDEA 97, the Congress states: "The Congress finds the following: Over 20 years of research and experience ha[ve] demonstrated that the education of children with disabilities can be made more effective by. . . strengthening the role of parents and ensuring that families of such children have meaningful opportunities to participate in the education of their children at school and at home [Section 601(c)(5)(B)]."

Students have a great deal to say and contribute to their own educational programs. Students can be IEPC members and can even lead their own IEP meetings. Transition services require student participation in the IEPC and must consider the student's interests and preferences.

Procedural safeguards are written into IDEA '97. These safeguards ensure protection of parental and child rights by mandating that children and parents are provided with necessary information concerning the special education process, decisions, definitions, rights, procedures, and directions for using the mechanisms in place to resolve disagreements.

The law requires parental notification and consent before the school may take any action affecting the child's special education programming. Examples include evaluations and IEP revisions. Parents are given access to all of their child's education records and evaluation reports (NICHCY 1998).

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Parents may not agree with a proposed action or may feel strongly that the school should take an action that the school has refused. The IDEA establishes procedures for conflict resolution. Mediation is the newest avenue for speedy and amicable resolution focused on the child's educational interests.

These, then, are six principles around which our nation's special education process is designed--a free appropriate public education, appropriate evaluation, individualized education programs, least restrictive environment, parent and student participation in decision making, and procedural safeguards. Alone, and together, they work to guarantee that children with disabilities can go to school every day, learn what other children learn, except perhaps in different ways, and have their individual needs identified and addressed (NICHCY 1998).

Parents must obtain details concerning the types and scope of services offered by schools and government agencies. In the process, families will confront many acronyms like IFSP, IEP, FAPE, MDT, ADA, IDEA, SLP and OTR as well as many procedural rules and guidelines. Because this can be overwhelming, contact a service agency for the deaf or hearing impaired and request a volunteer advocate to help work through the process of discerning and obtaining services (Dedert 1998).

An Individual Family Service Plan (IFSP) is a document covering eligible children from birth to age 3 that is administered by the local school district's office of early intervention services. It describes services of interest and services the child is receiving. The whole family is approached as a service team. Assessments and services may be free or provided on a sliding fee basis, depending on state rules (Dedert 1998).

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Also administered by the local school district is the Individualized Education Plan (IEP) which covers eligible children from ages 3-21. This annual document details the educational plan for a child based on the findings of a Multidisciplinary Evaluation Team (MET). Parents are part of the Individual Educational Planning Committee (IEPC)- that team of individuals who meet as often as needed to fine tune the plan, reassess the situation, state goals and objectives, discuss progress, and implement the plan.

The IEP process begins with a parental written request for evaluation or a referral. After written parental consent, the child is evaluated for suspected disabilities and learning strengths and weaknesses. The parent submits a parent report outlining observations, concerns, desires, and family perspectives. All parties meet as an IEPC to discuss all reports and create the IEP. All goals and objectives are written in measurable terms with details for progress reporting. Any member of the IEPC may call another meeting if they feel the plan is not working, or to consider new variables affecting the student's academic status. At a minimum, the IEP must be reviewed each year, and the student's progress must be reported at least as often as report cards are given to regular students.

The IEPC must decide on the best placement for the child that will result in meeting the child's goals and objectives. All programming and supplementary aids and services are provided by the school district in coordination with state and federal programs.

In 1990, the Americans with Disabilities Act (ADA) passed which prohibits discrimination against people with disabilities in areas of private employment, public accommodations and services, transportation, and telecommunications. This means that deaf and HI children cannot be excluded from daycare (Dedert 1998).

Auditory-Verbal International, Inc. (AVI) suggests the following protocol for audiological and hearing aid evaluations. The Auditory-Verbal Approach seeks to insure that maximum residual hearing is achieved. A battery of audiological tests is performed because no single procedure has sufficient reliability. Ideally, aural habilitation programs have audiological services on-site, but regardless of setting, it is essential that providers in audiology and therapy work closely together. Parents should be present for and participate in the administration of all assessments, regardless of the child's age.

Initial consultations should include a case history and parent observation report, an ostoscopic inspection, and tests of acoustic intermittence: tympanometry, physical volume, and acoustic reflexes. Approach test results with caution if the child is less than 6 months old (Auditory-Verbal International 1998).

Between birth and six months, an Auditory Brainstem Response (ABR) test is done which alternates click and tone pip response by air conduction and bone conduction. The ABR alone is not sufficient to diagnose hearing loss. Recommended first options are amplification and auditory learning, unless CT scan or MRI imaging confirm an absence of the cochlea. Next, behavioral testing, amplification, and therapy are indicated before a decision of no usable hearing is made (Auditory-Verbal International 1998).

Between 6 months and 2 years of age, evaluation is done by behavioral observations and visual reinforcement audiometry. Testers look for: (1) the detection and awareness of voice and warbled tones from 250-6,000 Hz in the sound field and/or 250-8,000 Hz under headphones; (2) startle response in the sound field, under headphones, and by bone conduction; and (3) auditory skill development (Auditory-Verbal International 1998).

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Between 2 and 6 years of age, tests of conditioned play audiometry are performed to get: (1) the response to pure tones from 250-12,000 Hz by air conduction and bone conduction, and from 500-4,000 Hz with masking at age 3.5 or over; and (2) the speech awareness threshold (the speech recognition threshold where language development allows) using Ling Five Sounds, body parts, tasks of speech perception, and/or formal tests like the WIPI (Auditory-Verbal International 1998).

Once children are over 5 years of age, standard audiometry tests of air and bone conduction are performed, as well as tests of speech recognition and speech/word identification (Auditory-Verbal International 1998).

When amplification options are chosen, certain protocols for assessment apply. An electro-acoustic analysis of hearing aids is done on the day of fitting and at 30-90 day intervals, at user as well as full-on volume, and whenever warranted by parental listening checks and behavioral observations. When hearing aids are repaired, internal settings are closely checked. The same protocol applies to FM systems (Auditory-Verbal International 1998).

Parents and therapists can help children prepare for tests of Sound Field Aided Response. Prepare the child by teaching consistent response to voice and the Ling Five Sounds. Aided measures should include: speech awareness or recognition; word identification at 55 dB in quiet and in noise; response to warbled pure tones from 250-6,000 Hz wearing binaural hearing aids, or monoaural measures to compare responses at each ear.

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AVI cautions: "It is important that the aided results be evaluated in relation to the unaided audiogram. Recommended aided results for the "left corner" audiogram with optimum amplification should be in the 35-45 dB (ANSI) range at 250, 500, 1000 Hz or better (Auditory-Verbal International 1998)."

In reference to probe microphone or real ear measures, get an unoccluded measurement of External Ear Effect as well as full occlusion with the hearing aid off to measure insertion loss. Insertion gain is measured with the hearing aid at customary settings in order to verify appropriate gain and output levels and to compare changes in settings. AVI cautions: "Existing formula may underestimate the gain required by children with severe to profound hearing impairment (Auditory-Verbal International 1998)."

Follow the following recommended schedules for assessment of aided and unaided systems. Check the system every 90 days (until age 3) once the diagnosis is confirmed and the amplification device is fitted." As early as possible, but at least by age 2, a complete unaided and aided audiogram should be obtained (preferably under headphones, but at least in the sound field.) (Auditory-Verbal International 1998)."

During the rapid growth typical from birth to age 4, new earmolds may need to be obtained at 90 day intervals. If progress is satisfactory in children ages 4 through 6, assessments may be done every 6 months. After age 6, assessments and new earmolds at 6-12 month intervals are appropriate. Of course, immediate evaluation should be scheduled if caretakers suspect a change in hearing or hearing aid function. Naturally, more periodic evaluations are required when middle ear disease is chronic or recurrent and when additional disabilities are present (Auditory-Verbal International 1998).

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All reports should be supplied promptly upon receipt of written release to parents, therapists, physicians and educators. A thorough report will include: (1) the test procedures and reliability assessments; (2) the complete audiogram with symbol key, calibration standard, and stimuli used; (3) hearing aid identification - make, model, output and tone settings, compression or special feature settings, volume setting, earmold style and quality of fit; (4) any FM system identification and settings; (5) interpretive information regarding the relationship of audiological findings to acoustic phonetics, especially with respect to distance hearing and message competition; and (6) an analysis of auditory behavior and development of the listening function (Auditory-Verbal International 1998).

Once evaluation and fittings are taken care of, Dedert offers families the following advice: Work towards having your child wear the amplification system full time as soon as possible. Continue to treat the hearing-impaired child as any other child. Talk naturally and frequently to the child about what is going on, staying within a 6 inch to 3 feet range and using natural volume, (increasing volume causes distortion) and keep background noise to a minimum (Dedert 1998).

Dedert recommends that families keep a journal of their experiences as they enter the process of evaluations and services for their hearing impaired child. Entries should include dates, names of persons or organizations contacted or involved, impressions, details of conversations, action promised, residual questions, to do lists, tests, conclusions, report details, and so on (Dedert 1998).

Dedert urges families to write down their hopes and fears, feelings about relocation to be closer to services, and placement of their child in a residential facility. Families are urged to record details of contacts made with organizations for literature and information on the availability of community resources. Visit community programs offering services for the deaf and hearing impaired and note details, services offered, contacts, impressions and questions, as well as location, date, and phone numbers. Visit or talk to other families experienced in living with hearing loss. Note their contact information, number of years experience, occupation, situation details, names, impressions, and so on (Dedert 1998).

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List all of the local resources available and categorize them according to philosophy: Auditory-Verbal, Auditory-Oral, Cued Speech, Total Communication, and American Sign Language (Bilingual-Bicultural). Make a chart to facilitate comparison of each option based on the following criteria: (1) likes, (2) dislikes, (3) impression of professionals as to appropriateness of the option, (4) compelling reasons to choose this option, (5) family opinions of appropriateness or inappropriateness of the option, and (6) expected adult outcomes for the child if this option is exercised (Dedert 1998).

Once educational options are chosen, it is necessary to monitor progress diligently, periodically asking if objectives are being accomplished in the given environment. It is absolutely appropriate to maintain high expectations for your child and open and frequent communication with service providers. Find out why a child is not making the progress he is capable of.

There are five main approaches to educating the deaf. These are (1) the Auditory-Verbal Approach, (2) the Bilingual-Bicultural (Bi-Bi) Approach, (3) Cued Speech, (4) the Oral Approach, and (5) Total Communication. Each school of thought will be discussed briefly.

Most children, even in cases of profound hearing loss, have some useable hearing that can be amplified to enable them to listen and talk. This is the mission of the Auditory-Verbal Approach. AVA rests on several principles: (1) Regular school attendance and a natural developmental integrated approach to communication and social development. (2) Deaf children can learn to listen, process language, and to speak with (3) regular A-V therapy involving parents and child, that is individualized, one-on-one, diagnostic and prescriptive; with (4) counseling and support services that facilitate participation in social groups, community, and regular education classrooms and activities (Schwartz 1996, 54-56).

It may take 6-18 months to assess whether the A-V approach will work. Weekly therapy sessions last 1-1.5 hours each (Schwartz 1996, 56-57). The A-V therapist presents goals and techniques that are practiced and applied by the parent in ordinary daily activities, some "structured" activities, and in song (Estabrooks and Birkenshaw-Fleming 1994).

The A-V team may consist of an ear, nose, and throat doctor, an audiologist, the A-V therapist, child and family, a psychologist, clinical geneticist, physical therapist, social worker, occupational therapist, family doctor, speech-language pathologist, and school personnel (Schwartz 1996, 57).

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The Bilingual and Bicultural Approach employs American Sign Language (ASL) for classroom instruction and teaches English as a second language through reading and writing (Reynolds 1994). Parents and students receive instruction in deaf culture that includes study of the history, values, customs, and contributions of the deaf community. Children develop a strong visual language (ASL) first, to give them necessary thinking and learning skills. They develop healthy self-esteem through interactions with other deaf individuals (Schwartz 1996, 90).

"You cannot sign ASL and speak English simultaneously" because they are two distinct languages (Schwartz 1996, 212). ASL is a language with its own grammar, syntax, and semantics, and is constantly evolving. It is a fast, efficient and complete language that gives children access to linguistic fundamentals during the developmentally critical first five years of life. Students of the Bi-Bi approach far outperform other deaf students both socially and academically (Schwartz 1996, 90-92).

Cued Speech is a system of hand shapes that represent speech sounds not letters. Eight handshapes represent groups of consonant sounds and four positions at the face represent groups of vowel sounds. Combinations of these signs show exact pronunciation of each syllable in connected speech. The result is a visible, understandable rendition of speech (Schwartz 1996, 118-120).

Consonants may look alike when formed with the lips, so different handshapes accurately identify them. By making the handshape at one of the four facial positions, the trained receiver knows the exact consonant-vowel combination (syllable). Since handshapes and facial positions cover a group of consonant or vowel sounds, the exact phoneme is determined by lipreading. Hense, cued speech is not a language of its own, but only a system of clarification of lipreading that cues exactly what is said exactly as it is said. It allows natural development of a child's native family language through a familiar phonetic approach to speaking, reading, spelling, and writing (Schwartz 1996, 118-121).

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Oral approaches require the child to use only speech for face-to-face communication, and avoid the use of a formal sign language. This is premised on the belief that visual strategies discourage hearing skills. Several philosophies fall into this group. A multisensory approach allows hearing, vision, and touch to teach children to understand and produce speech. The unisensory method relies on residual hearing without the benefit of lipreading. It stresses high academic achievement and maximum integration with hearing peers (Schwartz 1996, 163-167).

Since speech is meant to be heard, only 30% of speech information can be gleaned by lipreading, so methods like cued speech must be used to fill in the missing information. While written language also makes speech patterns fully available to the deaf, it also cannot teach them to produce speech because tone and speech rhythm are best transmitted through hearing. Therefore, unisensory, acoupedic and auditory verbal methods are inappropriate for the profoundly (90-120 dB) deaf (Schwartz 1996, 163-167).

The Total Communication approach aims to educate the deaf using a manual sign system (MCE or manually coded English) while amplifying residual hearing, and incorporating speech and speechreading. MCE is time consuming and places unreasonable demands on short term memory. Studies show that the average reading level of graduating deaf high school students falls between grades 3 and 4 (Schwartz 1996, 91-92).

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Total Communication programs may use a variety of strategies in combination or isolation to educate the deaf. These include: signs, gestures, speech, speechreading, amplification, and fingerspelling. Programs will vary in the strategies they emphasize. Simultaneous communication intends to provide linguistic input using an English-based sign system (not ASL). Children gather information through signs, speechreading, and listening as abilities allow. Signs and gestures are learned by family, student, and teacher and are employed immediately and consistently in tandem with speech. Some approaches allow participants to interchange strategies. Both views are based on the idea that language can be "visual and gestural as well as auditory and oral (Schwartz 1996, 212)."

Determination of an educational approach will be based on consideration of student and family needs, preferences, abilities, resources, and goals. Careful study and observation of each method is recommended before a decision is made. Most likely, the child will be educated at least minimally in a regular education classroom. Recommendations for the general instruction of the deaf in the educational mainstream follow.

At Stonewall Jackson Elementary School in urban Dallas, children consistently outperform other Texas children on standardized State exams. Stonewall is the site of the district program for the deaf, housing 75 mainstreamed deaf or hearing impaired students within a general population of 575 students.

Success is attributed to the blanket application of teaching methods for the deaf and hearing impaired to all students. Teachers give clear instructions slowly, repeat directions, make sure each child understands, eliminate confusion of expectations, and use methods that are rich in visual aids (Smith, Diller and McNarma 1995, 40-42). By eliminating confusing communication problems, all students proceed more confidently.

Because the hearing impaired rely upon visual cues (speaker's lips or interpreter's signing) the act of looking down to take notes creates gaps in comprehension. Children with auditory processing deficits and handwriting difficulties also benefit when a gifted hearing student within the class is employed to take organized, comprehensive notes of lectures, class discussions, and class activities. These notes, kept in a reference binder, and are made available to students needing them and are supplied to absent students (Low Incidence Support Center 1996).

Note takers are trained to produce organized, understandable notes which accurately capture the information presented as well as the details of integral classroom interactions. Key elements include the context of the lesson, questions and answers, examples discussed, assignment and test information, and class discussion details (Low Incidence Support Center 1996).

Clear notes consistently use organizational strategies such as boxing. circling, lettering, numbering, underlining, double underlining, asterisks, arrows, pointers (Low Incidence Support Center 1996), concept maps, flow charts, and other illustrations.

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Creating spaces for the hearing impaired complies with the American with Disabilities Act and results in building improvements that benefit all students. The five principles of sound school design are (1) visual music, (2) interplay of color and light, (3) unobstructed sight lines, (4) sensitive incorporation of technology, and (5) acoustical balance (Latimer, Birdsey and Mann 1994, 58-60).

For the deaf and hearing impaired motion is music. By integrating physical forms and kinetic activity, deaf and hearing impaired students can experience music in a building with open spaces and visual balance (Latimer, Birdsey and Mann 1994, 58-60).

Here are some tips to help a hearing impaired child enjoy music when integrated in a hearing classroom. The whole class can be taught to sign the words of songs. Start with one sign at a time and add more as mastery permits (Walczyk 1993, 42-44).

Use the keyboard as a graphic example of musical concepts like octaves and half steps. Sometimes a hearing aid can be attached to the keyboard, sufficiently amplifying sound so it is audible for the student, although some ranges will be more audible than others. If a child hears in the high range, then gear more singing and performances to that range. Ensemble performances help the hearing impaired experience the joy of music. An electronic keyboard can be set up to provide feedback for the student reading music (Walczyk 1993, 42-44).

Color and light, and open class layout have practical uses for the deaf and hearing impaired. The interplay of light and color can provide emergency and event notification, visual music, and can create pleasant sensory experiences devoid of glare and shadows. Optimum lighting levels are 75 footcandles and allow the extra light necessary for lip reading and signing. It is necessary to design the classroom so that it is free from visual obstructions. This allows the deaf or hearing impaired visual access to signers and the faces of speakers (Latimer, Birdsey and Mann 1994, 58-60).

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There is a trend toward equipping elementary classrooms with special audio-visual equipment that helps all children focus better on main activities. Teachers wear microphones and speakers are placed in each corner of the room. Large screen monitors display real-time captioning for the deaf and hearing impaired. This allows them to see as readily as the other students hear. Other useful technological aids include infrared and FM broadcast systems, strobe-light fire alarm and life safety systems, visual doorbells, computer chat, bulletin board systems, e-mail, and voice-to-text computer programs (Latimer, Birdsey and Mann 1994, 58-60).

Acoustical balance is achieved when building and classroom design minimizes sound reflection from floors, walls, and ceilings. The deaf and hearing impaired are generally able to hear low frequencies, but not middle and high frequencies, and are sensitive to low frequency and infrasonic noise, felt as vibration (Latimer, Birdsey and Mann 1994, 58-60).

Teachers can employ the following suggestions to optimize learning in the heterogeneous classroom: Model a positive attitude toward the deaf and hearing impaired. Avoid moving around too much and lowered expectations for special students. Speak at a moderate pace facing the students, not the black board, and do not exaggerate mouth movements or shout. Stand away from and not in front of windows or bright lights. Use visual aids when possible, using the board for lesson outlines, new vocabulary lists, homework details, assignments and due dates. Identify classroom speakers, repeat questions asked by students, and provide the deaf and hearing impaired with a note taker.

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Use captioned films and video whenever possible and communicate regularly with parents (Latimer, Birdsey and Mann 1994, 58-60).

When speaking, be sure not to block your mouth, and avoid nodding your head. Reduce the general noise level whenever possible and give preferential seating to those who would benefit from it. Make sure body language and speech are natural. Repeat key ideas and rephrase, using the board to note and illustrate important items. Inconspicuously check for comprehension and take care to avoid chalkboard glare (Fann 1995, 78-81).

Terpstra offers several suggestions for successful integration of hearing impaired students with hearing students. In a mixed classroom, no more than one-third of the students should be deaf or hearing impaired and they should have their own teaching team and interpreter or signer. Throughout lessons, hearing students and teachers are taught and use signing also. Eventually, hearing students are able to communicate with their deaf peers in a more comfortable way (Terpstra 1996, 12-15).

Paul Taylor, associate professor at the National Technical Institute for the Deaf in Rochester, New York advises using both group and individualized instruction in the mixed ability classroom. Students are grouped according to learning style. A common communication style is found and is used primarily for general class instruction. Computer programs, using the common mode (ex: reading) are used for review, assessment, tutorials, and progress reporting.

The "usual lecture, written assignment and exam" method of instruction was found unsuitable for deaf and hearing impaired students. Taylor found that "sensory-thinking" learners benefited most from computer paced instruction because it is "organized, systematic, activity-oriented, and instructor-directed."

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Taylor found students motivated to learn when feedback was frequent, concepts were modeled and graphically illustrated on a computer monitor, and when the teacher was readily available for clarifications. Students responded well to alternative forms of assessment, especially "individually paced competency-based assignments." Classroom time is used to work through difficult problem-solving activities for students lacking the personal discipline required for student paced computer instruction. Points were given for completion of units with letter grades determined by point spreads (Taylor n.d., 333-337).

Sign language can be fun to learn for young hearing students and is a way to expand the social world of hearing, deaf and hearing impaired students. American Sign Language (ASL) is the third most popular language used in the United States (Reynolds 1995, 2-6).

Peak interest by using games and songs. Tailor lessons to fit children's experiences, vocabulary, and perspectives. Realize that perfection is a developmentally inappropriate expectation. Use gentle physical assistance to establish the mind-muscle connections for signing. Be flexible enough to make lessons reflective of student interest and stamina (Reynolds 1995, 2-6).

It is also helpful to assign each hearing impaired student a hearing buddy whose job it is to clue the HI student into changes in focus, classroom events, and assignments. The buddy accompanies and directs the HI student during tornado and fire drills and helps to ease confusion and insecurity. The hearing buddies learn responsibility and compassion, and gain confidence and esteem in themselves and their HI partners (Reynolds 1996, 15-16).

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When teaching sign language to preschoolers, keep lessons at or below 30 minutes, concentrating on each signing activity for about 5 minutes and always gearing lessons to the attention span of the youngest child in the group. Alternate voice and silent activities, accept approximations, and involve other preschool staffers in sign language, which serves as a model for students. Model alphabet fingerspelling within the context of ordinary lessons. Individualize lessons by polling the students for new words to learn. Call on children by name to demonstrate newly learned words and phrases for the class (Dr. X 1998).

Palentine, Inc. (1-800-475-1119) manufactures software capable of translating any kind of letters, numbers or words into fingerspelling hand signs. The Interactive Sign Language: Fingerspelling and Numbers program teaches the basics, and improves comprehension and signing speed through the use of photographs and hand animations. It runs on Windows and Macintosh platforms (Palentine 1994, 34).

Deaf and hearing impaired students can learn mathematics using the many hands-on concrete learning tools available. Most of these items are available from Tri-Con Publishing's Mathematics and Science Catalogue.

Teaching math with hands-on concrete tools benefits all students. A Geoboard is a plastic studded board with square grid lines that students use to layout geometric shapes with multicolored rubber bands. By counting the number of squares within a shape, students can discover its area, then use a math formula to arrive at the same conclusion by multiplying the number of squares on one vertical side by the number of squares along the horizontal side (Brosnan 1997, 18-22).

This also demonstrates the multiplication tables, as 5x4=20 or a shape enclosed by a rubber band that is 5squares high x 4 squares wide always equals a rectangle containing an area of 20 squares (Brosnan 1997, 18-22).

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A process oriented approach to science teaching was found to redresses the imbalances between academics and language in hearing impaired individuals. Cooperative learning experiences serve to facilitate natural communication skills and foster student independence. While using hands-on experiences, the teacher continually assesses student participation, progress and learning styles, adjusting activities to meet student needs until academic objectives and independent functioning are achieved (MacIntosh, Sulzen, Reeder and Kidd 1995, 480-485).

It is important to develop maximum reading comprehension for deaf and HI students because they receive a majority of academic information in print form. All students benefit when asked to formulate their own questions about text before reading. Self-interest, motivation, previewing, class discussion, and total group comprehension all increase with these methods (Roshine, Meister and Chapman 1996, 181-219).

All students are taught basic strategies for relevant question generation, and answer who, what, when, where, why, and how. For stories, students create a diagram with spaces for setting, main character, character goals, obstacles, etc. Student questions become part of reading tests (Roshine, Meister and Chapman 1996, 181-219).

The Language-Experience Approach was designed to teach reading and writing to HI students but is useful for all students. Students generate the content that they will read by writing, signing, or dictating to the teacher or aid who then returns a printed or written version. Students watch their dictation become transformed into written form. This approach combines the graphophonic, semantic, and syntactic language cue systems into motivating and meaningful language arts exercises (Ewoldt and Hammermeister 1996, 271-273).

Approaching any degree of deafness or hearing impairment is agonizing and complicated for families. Serious life-long choices must be made that directly influence the child's social and academic future. Choices in testing, amplification, communication, and education all must be made in light of federal and state education and civil rights laws, as well as local community and educational resources, and family preferences.

Because the latest laws require that deaf and HI children be educated to the maximum extent possible with their hearing peers, chances are great that HI students will receive a good deal of instruction in regular schools and classrooms. This affords many opportunities for normal interactions with peers and greater participation in ordinary peer and community activities. By preventing isolation of HI students, the new laws ensure more hopeful outcomes for the academic, social and economic futures of disabled persons.

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