Including Deaf and Hard of Hearing Students in the General Education Classroom

Abstract
This paper provides an extensive review of literature on deaf students and deafness. The purpose of the literature review is to obtain an understanding of what deafness is, what causes deafness, how it occurs, and what deaf culture is like for deaf people. The review identifies schools and programs that are used to help the deaf community and it also examines the outcomes of deaf students in general education. It discusses whether deaf students are better served in an inclusive environment or whether they are better served in a deaf community based learning environment. It examines the characteristics of hearing loss and how there are different tools and ways to treat hearing loss when it occurs in cases where reversing the hearing loss is possible. In some cases, reversal is not possible but surgical solutions may exist.
Introduction
One of the more remarkable qualities of deaf culture is that those who are deaf or hard of hearing look at the other person with whom they are speaking. In hearing culture, it is not uncommon for people who are speaking to one another to look away from one another when speaking, to break or even avoid eye contact, or to use technology such as phones to communicate. Deaf culture is much more dependent upon face-to-face communication and the use of signs—pictures—to convey meaning, whereas in hearing culture, people think generally in terms of words.
Deaf culture is an intriguingly unique culture in the world for this reason and it is one that I am fascinated by. In seeking to promote inclusivity in the classroom, I believe it is important to understand other cultures and deaf culture is one that often receives little attention. Gaining insight into how the deaf and hard of hearing experience their reality can be helpful to educators as they honor their commitment to diversity and inclusivity. The more cultural competence that educators obtain, the more likely they will be to exert a positive influence on others.
The deaf community is one that has often been overlooked in popular culture, it is worth an investigation. However, in recent years there have been some steps taken towards shining light on this community in different artistic ways. The 2014 Ukrainian film The Tribe was a dialogue-free film featuring deaf actors using Ukrainian sign language without subtitles and was celebrated by critics for creating a unique cinematic experience for viewers unfamiliar with what life is like for the deaf community. Todd Haynes’ 2017 film Wonderstruck focused on a deaf child and a hard of hearing child. In 2020, the Marvel Cinematic Universe (MCU) plans to release The Eternals, which features the first deaf superhero in the MCU. As deafness is beginning to receive more attention in popular media and culture, it can be helpful to understand what deafness is in reality.
Definition of Terms
· Communication Disability—an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems, which can be manifested in hearing, language use and speech
· Deafness—a lack of or deficiency in the sense of hearing
· Deaf Community—members have their own social and behavioral characteristics but do not view themselves as impaired
· Deaf Culture—the set of values, social beliefs, traditions, customs, shared communities, behaviors, art, and history informed by the experience of deafness and in which the participants of that experience use sign language as the main method of communication
· Hard of Hearing—having a defective or impaired but functional sense of hearing
· Hearing Impairment—unable to hear well
Review of Literature
The History of Deafness/Hard of Hearing
The first free public school for the deaf was created in 1760 by a French Catholic priest. Prior to that, it was a Catholic Benedictine in the 17th century who focused on developing a method for teaching deaf students: his name was Pedro Ponce de Leon. In 1788, the first French sign language dictionary was published. In the 19th century, Alexander Graham Bell, who had a hard of hearing mother, started the Volta Bureau School for teaching hearing impaired children.
At the end of the 19th century, the first hearing aids were developed. A century later, the very first cochlear implants were being tested. The cochlear implant, also known as the Bionic Ear, was pioneered in development by Professor Graeme Clark in Australia (1960s) and first successfully used in 1978 (Hill, 2019). This technology can help deaf people to hear speech and can assist them in learning to speak, and currently more than 13,000 children use the Bionic Ear (Hill, 2019). These implants consist of an electronic element that is surgically implanted into the ear: it comes with a small, exterior microphone that goes around the ear, along with a speech processor, a transmitter and a sender/receiver.
The primary means of communication for the deaf, however, remains sign language. The most widely used system is the American Sign Language system. It grew out of a combination of the signs used by the deaf community situated in Martha’s Vineyard, Massachusetts; the French Sign Language system, and signs developed at the Royal Institution for the Deaf. Gallaudet established the first school for the deaf in the U.S. The National College for the Deaf and Dumb was established by Gallaudet’s son in 1864. These schools were the first to use American Sign Language.
While deafness is often considered as a handicap, there are many celebrated deaf people who have achieved much. Helen Keller, for instance, was born both deaf and blind, and she learned to communicate thanks to an innovative signing technique taught to her by Anne Sullivan. Keller went on to become a famous lecturer. The sign language system used in baseball was developed by a deaf ballplayer. There are also numerous artists and professionals who have succeeded in spite of deafness (Arizona Office for Americans with Disabilities, 2007).
Deafness and IDEA
The Individuals with Disabilities Education Act (IDEA) (2006) states that “each public agency must take steps, including the provision of supplementary aids and services determined appropriate and necessary by the child’s IEP Team, to provide nonacademic and extracurricular services and activities in the manner necessary to afford children with disabilities an equal opportunity.” Deafness is one of the 13 disabilities covered under IDEA, which means schools must provide special education services to deaf students who qualify. Students who qualify are those whose academic performance is adversely affected by their disability. If this is the case, the school must make efforts to provide services designed to support the child’s disability.
IDEA defines deafness as “a hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification.” IDEA defines hearing impairment differently—as “an impairment in hearing, whether permanent or fluctuating, that adversely affects a child's educational performance” (Project Ideal, 2019). While the two definitions are similar in that they both identify the problem as a hearing impairment, they differ in terms of where the problem is in terms of outcome. For deaf students, the impairment impacts the child’s ability to process linguistic information through hearing, and for hard of hearing students, the impairment impacts the child’s academic performance.
Characteristics
There are 4 types of hearing loss. These types are determined by where the impairment is centrally located in the auditory system.
Conductive Hearing Loss is the first type and is categorized based on the damage or obstruction found in the external or middle ear. This damage or obstruction disrupts the passage of sound waves and vibrations through the chambers of the external or middle ear. Once identified, most cases of conductive hearing loss are treatable. The problem with this type of hearing loss is that it can impact the child’s development of oral language usage and lead to speech impairments.
Sensorineural Hearing Loss is the second type of hearing loss and is caused by damage affecting the inner ear (cochlea) or impacting the auditory nerve, which sends impulses to the brain. Sensorineural hearing loss is usually more severe than conductive hearing loss and tends to be permanent. Thus, it typically negatively impacts oral language development to a large degree.
Mixed Hearing Loss is the third type of hearing loss and occurs when there is some combination of both a conductive and a sensorineural hearing loss.
Central Hearing Disorders are the fourth type of hearing loss and they result from a dysfunction occurring in the central auditory system somewhere between the brain stem and the brain’s auditory cortex.
Genetic or hereditary factors that impact hearing loss are not uncommon. Genetic mutations can result in hearing loss. Otosclerosis, Usher's syndrome and Pendred syndrome are a few examples of hereditary genetic disorders that result in hearing loss (Sheffield & Smith, 2019).
Prenatal infections caused by toxoplasmosis, rubella, cytomegalovirus, and herpes; as well as postnatal infections like bacterial meningitis can lead to hearing loss. This is typically the case in developing nations (Shearer, Hildebrand & Smith, 2017). In the developed world, however, the typical infection leading to hearing loss is the congenital cytomegalovirus (cCMV) infection (Shearer et al., 2017).
Developmental abnormalities that can result in hearing loss are when both dominant and recessive genes exist: this is known as congenital hearing impairment. Structural developmental abnormalities in the ear are numerous and include microtia, anotia, aplasia, and other anomalies (Hill, 2019).
Environmental or traumatic factors that lead to hearing loss include fetal alcohol syndrome (Hill, 2019). Exposure to ototoxic drugs can also lead to hearing loss; these drugs include:
· Aminoglycoside antibiotics, which can degenerate the inner hair cells and thus cause hearing loss
· Chemotherapeutic agents, which can lead to cochlear metabolism toxicity
· Salicylates, which can also lead to cochlear metabolism toxicity; however, in this case the loss can be reversed
· Nonsteroidal anti-inflammatory drugs, which can likewise lead to reversible cochlear metabolism toxicity
· Quinine, which can like chemotherapeutic agents, lead to cochlear metabolism toxicity
· Loop diuretics, which can degenerate inner hair cells like aminoglycoside antibiotics
· Erythromycin, which might have an impact on a child’s central nervous system pathways
Diagnosis of Hearing Impairment
Diagnosing hearing impairment can be achieved through a variety of different exams, from physical tests to tuning fork tests to general screening tests to audiometer tests. Shearer et al. (2017) note that physiologic tests are used to assess the functional status of the individual’s auditory system and can be performed at any age. These tests include:
· Auditory brain stem response testing—uses audible “clicks” to stimulate electrophysiologic responses
· Auditory steady-state response testing—uses a mathematical algorithm to identify limits of hearing for the person
· Evoked otoacoustic emissions—uses a probe to measure sounds that originate in the cochlea to assess the activity of outer hair cells
· Immittance testing—used to assess the peripheral auditory system
Other tests include audiometric evaluations, which determine how effectively the person is able to process auditory information. It relies on behavioral assessment and includes some of the following examinations:
· Behavioral testing—uses behavioral observation audiometry and visual reinforcement audiometry; the former is performed on infants up to 6 months of age, and the latter on children up to 2.5 years of age
· Pure-tone audiometry—determines the lowest intensity at which an individual can hear a pitch
· Conditioned play audiometry—tests frequency hearing in each ear of a child between the ages of 2.5 and 5 years of age
· Conventional audiometry—used with people from the age of 5 and up; a sound is played and the person indicates when the sound is heard
· Audioprofile—forms a profile of age-related deafness within a family.
Newborn hearing screening can be conducted to identify congenital hearing loss (Shearer et al., 2017). Children who display delayed speech development should have their auditory system checked.
The tuning fork test is commonly used to test for sensorineural and conductive deafness. In the Weber test, the base of a gently vibrating 512-Hz tuning fork is placed at the midforehead or vertex of the head and the individual indicates which ear hears the sound best.
Wax blockage can sometimes be a cause of hearing impairment and can be diagnosed using an otoscope. A curet or suction device can be used to remove wax blockages. Or it can be flushed out using a syringe and warm water.
Surgical procedures for hearing impairment such as Otosclerosis can be conducted to remove bone. Other procedures for impairment include hearing aids or the cochlear implant, which is a way of bypassing damaged sensory hair cells. The electronic element is implanted in the ear, a microphone is placed around the ear, and a receiver and sender are attached (Hill, 2019).
Causations
Acquired hearing loss can occur as a result of infections (Shearer et al., 2017). Toxoplasmosis, rubella, cytomegalovirus, and herpes), or postnatal infections, such as bacterial meningitis can all lead to hearing impairment. Congenital cytomegalovirus is the most common cause of infection in developed countries. Hereditary causations can be malformations of the external ear, or abnormalities of the middle ear and/or inner ear. 4 out of 5 cases of prelingual deafness is genetically caused (Shearer et al., 2017).
Conductive Hearing Loss happens when there is an issue in the ear’s ability to transfer sound waves in a path through the outer ear, the eardrum), or through the middle ear.
Sensorineural Hearing Loss is permanent and occurs when the inner ear is damaged or when the nerves that connect the ear to the brain are dysfunctional. With this kind of condition, even loud noises may appear like nothing more than a muffled murmur to the individual.
Mixed Hearing Loss is basically a combination of conductive and sensorineural hearing loss. The issue can be in the outer or inner ear or with the auditory nerve. It can be cause genetically, as a result of external trauma, or by infection 
Central Hearing Loss is the result of caused by a lesion occurring either in the central auditory pathway or else in the auditory cortex. The auditory cortex irs responsible for handling and interpreting sounds amplified and received by the ossicles and cochlear hair cells (Curhan & Curhan, 2016).
Otosclerosis results from abnormal bone growth of bone in the middle ear. The abnormal growth causes obstruction and prevents the ear from being structurally effective for hearing.
Meniere’s Disease is an issue within the inner ear and can cause vertigo but also hearing loss. It is typically only found in one ear, but it can occur at any age, and onset typically begins anywhere from young adulthood to middle-aged adulthood.
Presbycusis is the most frequent and typical type of Sensorineural Hearing Loss and is triggered simply by the effects of natural aging. Onset is gradual rather than sudden and in the beginning stages it only impacts the person’s ability to hear higher pitched sounds.
Very Loud Noises can be very damaging to the inner ear (cochlea). Even just a one-time exposure to very loud noise (such as a gun going off at one’s ear) can be enough to cause hearing loss. Listening to loud sounds for an extended period of time can also cause hearing loss, as it overtaxes the hair cells in the ear and they can die from exhaustion.
Acoustic neuroma is a benign tumor that forms on the vestibular, or on cochlear nerves. If on the latter, the pressure placed on the nerve from the tumor can lead to hearing impairment.
Physical head injury can cause hearing impairment similarly to loud noises by damaging the auditory pathway.
Autoimmune inner ear disease is rare but when it occurs, it is the result of the body’s immune system attacking the inner ear by mistake. It is only found in 1% of the 28 million Americans who suffering from hearing impairment.
Ototoxic medications such as quinine, aspirin and other salicylates can cause high-pitch tinnitus and hearing impairment in both ears. The issue can be reversed upon discontinuation of the usage of the drug (Curhan & Curhan, 2016).
Methodologies
Different forms of methodologies exist for coping with hearing impairment and deafness. Depending on the degree of impairment, the forms can vary to a wide degree. In general, these forms include:
· Auditory-Oral methods, consisting of Natural Gestures, Listening, Speech (Lip) Reading, Spoken Speech
· Auditory-Verbal methods, such as Listening, engaging in Spoken Speech
· Bilingual methods, such as learning and using American Sign Language and English together
· Cued Speech methods, such as Cueing, Speech (Lip) Reading
· Total Communication methods, such as Conceptually Accurate Signed English (CASE), Signing Exact English (SEE), Finger Spelling, Listening, Manually Coded English (MCE), Natural Gestures, Speech (Lip) Reading, Spoken Speech (Centers for Disease Control and Prevention, 2019).
Deaf Culture
Deaf culture is the set of values, beliefs, experiences, and expressions of people who are impacted or influenced by deafness or hearing impairment and who typically use some form of sign language to communicate (Padden & Humphries, 2005). The deaf community views deafness merely as a difference in human experience and not as a disability, though the able-bodied community does view deafness as a disability. Thus, there is a difference in perspective between the hearing community and the deaf community.
Deaf culture is not exclusive but rather overlaps with other cultures, including ethnic cultures, national culture, religious culture, gender, class and myriad other cultures as well. It is diverse but the common thread that unites members of deaf culture is the effect of deafness on the lives of those who are in the deaf community, whether they are deaf themselves or whether they are family or friends of a deaf person and have learned to sign to communicate.
Technology has become increasingly useful in deaf culture as individuals are able to use digital technology to communicate more effectively both with others within the deaf community and those who are not deaf nor of the community (Padden & Humphries, 2005). Individuals within the deaf community embrace any tools and methods that can facilitate communicate with other deaf persons and hearing persons. The deaf community is not elitist in any way nor is deaf culture isolationist in nature: members of the deaf community have as much stake and interest in the world of non-hearing impaired individuals as they do with identifying ways to maneuver through life in their own terms. The strategies and friendships they form, and the networks and connections they make are part of their deaf experience but they do not make up the totality of their world or confine them to a world of only interactions with other deaf individuals.
Programs
Gallaudet University is the only liberal arts university for the deaf to be founded in the U.S., and it was established in 1876. It maintains an extensive library of works on deafness. A Library Services for the Deaf and Hard of Hearing exists in Nashville and was created to assist the deaf in accessing materials. Gallaudet University serves as the main hub of activity for program development for the deaf in the U.S. (Gallaudet University, 2019). However, as the university points out, there are numerous schools and programs for the deaf around the nation now, including:
· American School for the Deaf in West Hartford, CT
· Alabama School for the Deaf in Talladega, AL
· California School for the Deaf in Fremont
· Delaware School for the Deaf
· Indiana School for the Deaf
· And many others
Nearly every state has a school for the deaf and programs are often started or funded as a result of collaboration between state or local governments, federal grants, or local leaders seeking to assist a minority population like the deaf by developing a program to facilitate the deaf community’s growth and progress.
An effective program for the deaf consists of education, like that offered by Gallaudet University. However, there are numerous other resources that show what a successful and effective program for the deaf can look like. Gallaudet University (2019) provides numerous examples. For instance, that there is the Three-module resource designed at the Clerc Center in collaboration with Educational Regional Center 20 in Texas for educators in general education settings: these modules give basic instruction and information on how teachers can assist deaf and hard of hearing students (Gallaudet University, 2019).
Deaf culture is very open to any program that provides support for the deaf community as it is viewed as something that enhances their culture and makes it stronger. The main ethos of deaf culture is that the deaf do not see their deafness as a disability but merely as a difference and therefore they embrace it as something that is empowering rather than as something that is oppressive.
Inclusion and Deafness
Because the deaf community does not want to be seen as something separate or that needs to be isolated like a group with a disease, deaf students prefer inclusion in general education classrooms (Hyde, Nikolaraizi, Powell & Stinson, 2016). Schools are also typically open to inclusion and will work with teachers, students and families to create a learning environment that is appropriate.
However, inclusion is not necessarily going to lead to effective education in every case, as there are numerous factors that will impact the situation—from the teacher’s abilities, to the school’s support system, to the reactions of peers, the classroom culture, and the student himself. As Hyde et al. (2016) show, deaf and hard of hearing students often enter higher education having attained fewer academic goals and skills than their hearing peers. This is an indication that the inclusive approach might not be the most effective approach. Instead, what may be required is a case by case approach to deaf and hard of hearing students—or enrollment in a deaf and hard of hearing school.
Education outcomes are typically lower for deaf and hard of hearing students, and school performance is typically sub-standard in cases where inclusion in general education is the aim rather than in cases where the deaf and hard of hearing students are in their own deaf culture learning environment (Hyde et al., 2016). However, if there are available sufficient and effective supportive services for deaf and hard of hearing students then the outcomes can be improved. The problem is that in many cases these supportive services are not available in a very meaningful or substantial way. Usually it is merely the bare minimum of services in order for the school to meet state and federal guidelines as dictated by IDEA.
Another outcome is that deaf students tend to score lower in social competence than hearing students (Wauters & Knoors, 2007). They tend to be more socially withdrawn than hearing students when in a mixed environment. This could be one of the drawbacks of inclusion, as the deaf students finds himself lacking a strong social support system that would otherwise be found in a deaf community schooling environment. However, Wauters and Knoors (2007) also showed that deaf students do not experience marginalization or exclusion from peers; on the contrary, they show that peers are generally accepting of deaf students and that friendships are stable over time.
Still, as Wauters and Knoors (2007) point out, when deaf and hard of hearing students transfer to college level, they tend to lack the skills to make that transfer successfully. School performance may be sufficient and peer relationships stable, but most are not prepared sufficiently to handle the transition or to make the most of the opportunity. Too many fall through the cracks as the researchers show.
Teacher preferences tend to be for inclusion as this is the general trend in most schools today; however, there is also the sense that deaf and hard of hearing students would benefit from a support system within a deaf community educational environment and if this is something that is available, it is typically discussed between parents and teachers to see if it is a viable option or one that would be in the best interest of the student.
Summary of Review of Literature
The literature shows that deaf culture is not something that deaf people are ashamed of: they see deafness as a way of life and not as a disability. The deaf community is supportive and takes advantage of supportive tools and technologies that facilitates their ability to interact with others. The deaf community and culture often overlaps with other cultures and communities, so it is not as if deafness is a phenomenon that is isolated geographically. However, there are schools and programs for the deaf that typically provide opportunities for deaf and hard of hearing students to learn in a deaf community environment.
Still, deaf and hard of hearing students are one of the disabilities that are included under IDEA, meaning that the hearing world views deafness as a disability—which naturally creates a distinction in terms of perspective between hearing persons and deaf persons. Teachers and schools tend to be inclusive towards deaf students, but depending on the support systems they have in place they may not be able to offer the kind of support the deaf need. Inclusivity is welcome and wanted when it can be fulfilled effectively, however.
Conclusion
Including deaf and hard of hearing students in the general education classroom should be a goal, as the deaf community does not want to be seen as disabled but rather only as different (and not in a bad way). Schools and teachers should take advantage of the tools and technologies available to facilitate interaction between deaf students and hearing students and teachers so that they can provide a more agreeable and supportive interaction between personnel and allow deaf students to reach the goals and objectives that they have set for themselves.
References
Arizona Office for Americans with Disabilities. (2007). Retrieved from https://know-the-ada.com/t4/history-deafness.html
Centers for Disease Control and Prevention. (2019). Retrieved from https://www.cdc.gov/ncbddd/hearingloss/language.html
Curhan, G., & Curhan, S. (2016). Epidemiology of hearing impairment. In Hearing Aids (pp. 21-58). Springer, Cham.
Gallaudet University. (2019). Retrieved from https://www3.gallaudet.edu/clerc-center/info-to-go/national-resources-and-directories/schools-and-programs.html
Hill, M. (2019). Embryology Sensory - Hearing Abnormalities. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Sensory_-_Hearing_Abnormalities
Hyde, M., Nikolaraizi, M., Powell, D., & Stinson, M. (2016). Critical factors toward the Inclusion of deaf and hard-of-hearing students in higher education. Diversity in deaf education, 441-472.
Individuals with Disabilities Education Act. (2006). Retrieved from https://sites.ed.gov/idea/
Padden, C. A. & Humphries, T. (2005). Inside Deaf Culture. Cambridge, MA: Harvard University Press.
Project Ideal. (2019). Hearing impairments. Retrieved from http://www.projectidealonline.org/v/hearing-impairments/
Shearer, A. E., Hildebrand, M. S., & Smith, R. J. (2017). Hereditary hearing loss and deafness overview. In GeneReviews®[Internet]. University of Washington, Seattle.
Sheffield, A. M., & Smith, R. J. (2019). The epidemiology of deafness. Cold Spring Harbor perspectives in medicine, 9(9), a033258.
Wauters, L. N., & Knoors, H. (2007). Social integration of deaf children in inclusive settings. Journal of deaf studies and deaf education, 13(1), 21-36.