Deaf and Hard of Hearing Students with Disabilities: An Evolving Landscape

Abstract

The population of students who are d/Deaf or hard of hearing (d/Dhh) with a disability have unique educational needs. Various terms have been used to describe this population, including “deaf plus”, “deaf with additional disabilities”, and most recently, “deaf with disabilities (DWD)”. Currently, there is no agreement on the percentage of DWD students in PreK-21 settings but is considered to comprise at least 40–50%. An individual who is DWD has a hearing loss and one or more disabilities, including (but not limited to) visual impairment or blindness, autism spectrum disorder, intellectual or developmental disabilities, specific learning disabilities, health impairments, etc. The critical consideration is that the interaction between hearing loss and the disability(ies) is not simply additive but rather multiplicative, impacting communication, cognition, social development, and behavior. Furthermore, the presence of hearing loss may decrease accurate identification of other disabilities and vice versa. Although the incidence of students who are DWD is quite high, there is inadequate research as these students are often excluded from studies focused on children who are d/Dhh. This article explores what we currently know about DWD students, and the knowledge and skills needed by teachers in the 21st century to meet the needs of these students and their families.

1. Introduction

The diversity across the population of individuals who are d/Deaf or hard of hearing (d/Dhh) with complex needs (hereinafter referred to as deaf with disabilities, DWD) is considerable. A person who is DWD is an individual who has a hearing loss and at least one other disability (e.g., visual impairment or blindness [VI], autism spectrum disorder [ASD], intellectual or developmental disabilities [ID], specific learning disabilities [SLD], health impairments, etc.). The possible combinations can include one or more disability(ies), and the impact of the disability may be relatively minor to severe. “Similar to students who are d/Deaf or hard of hearing (DHH), students who are DWD vary in terms of degree, type, and age at onset of hearing loss, amplification, and preferred communication method. However, students who are DWD are also diverse in terms of type, etiology, and number and severity of disability(ies)” [1] (p. 134). Furthermore, the presence of hearing loss can make it more challenging to identify the disability, while the disability may mask the effects of the hearing loss. Over the past few decades, more attention has focused on educating students who are DWD; however, there is still much ambiguity concerning prevalence, assessment procedures, and teaching best practices. Additionally, there is a lack of qualified personnel to provide educational services to students who are DWD. We acknowledge that similar to views of deafness, DWD may be seen by some as a disability, but not by all; we respect the opinions of professionals from both perspectives. We have used DWD [2] to include students who are Deaf, deaf, or hard of hearing who have a disability. We have also used terminology frequently used by researchers in the Special Education field.

2. Historical Perspective

This population of students has been identified by several different terms throughout the years, both in research and in practice. Terms such as “deaf plus” and “deaf with additional disabilities” sought to describe the impact of the co-occurring disability with the hearing loss. However, Paul [2] posited the term “deaf with disabilities” (DWD) as an inclusive term to better capture the intersection of various disabilities with hearing loss. In this article, we will discuss DWD in broad, general terms. For a more in-depth look at various sub-populations (e.g., d/Dhh with autism, with learning disabilities, with intellectual disabilities, etc.), the reader is referred to Deaf and Hard of Hearing Learners with Disabilities [3].

The population of students who are DWD has not been historically or thoroughly investigated. Paul [2] suggested this is a complicated task due to several challenges that have been evident for many years and still persist today. These areas include challenges in “identification, classification, assessment, selection of instructional and curricular activities, management, and educational goals” (p. 340). In this article we will detail what is currently known in these areas and suggest what parents/caregivers, teachers and professionals need to know to effectively educate students for the 21st Century.

3. Prevalence

van Dijk et al. [4] explained that there are multiple etiologies of deafness and co-occurring conditions and that these may or may not have the same cause. They categorized the co-occurrences into three categories depending on when they presented: prenatal onset, perinatal onset, and postnatal onset. The first category includes genetic syndromes and maternal illnesses during pregnancy. The second category includes prematurity and trauma associated with the birth process. The final category includes acquired causes, including infant trauma, illnesses, or infections. Obviously, the amalgamation of etiology, the onset of the disability, and the characteristics of the disability impact the child’s functional abilities in varied ways.

While some studies have investigated the prevalence of DWD students in the classroom, the numbers are estimates at best. The literature indicates that of the number of students who are d/Dhh, between 25% to 51% are students who are DWD [5,6,7,8,9,10]. However, Guardino and Cannon [8] explain that these numbers are difficult to calculate due to inconsistencies in how organizations/agencies report and label special education services. Further, teachers report [8] that these numbers significantly underrepresent the students they serve. In fact, the numbers reported by teachers of students who are DWD in their classrooms and caseloads were one and a half to six times higher than those noted in Gallaudet University Research Institute’s report (GRI) across disability areas.

While disabilities are identified across all 13 IDEA disability categories [11,12,13,14] of the reported additional disabilities, SLD, ID, ASD, and deafblindness (DB) are the most prevalent [1,11]. Important to understand is that students who are DWD may (1) experience one or more disabilities, (2) exhibit various degrees of impact from the additional disability, and (3) encounter multiplicative effects of the combined disabilities, which impact their behavior, cognition, communication, and physical and social development [13,15,16].

One of the primary reasons the prevalence of DWD students is underrepresented is that schools often label students for special education services under a primary disability category or in a multiple disabilities category but may neglect the secondary category, including hearing loss. The requirement to designate one over the other has significant repercussions in educational placement and programming [11]. The critical consideration for Individualized Education Program (IEP) teams is that the interaction between the hearing loss and the disability(ies) is not simply additive but rather multiplicative [1,4], impacting communication, cognition, social development, and behavior. The unique needs of the DWD student, rather than the specific label(s), should dictate educational services, placement options, accommodations, and modifications. Guardino and Cannon [9] describe these unique challenges across “academic, social, emotional, and/or behavioral needs, across both deafness and all disability areas” (p. 2).

4. Research and Educational Resources

It has long been recognized that there is a lack of both research regarding teaching best practices [7,16,17,18] and resources available that address the population of learners who are DWD. Ferrell, Bruce, and Luckner [19] state that there are many reasons that research is complicated when focusing on education for students with sensory disabilities. They specifically mention issues related to the geographic disbursement of students, the heterogeneity of the population with various diagnoses, additional disabilities, and levels of functioning. The ability of researchers to conduct studies that reach the “gold standard” (rigorous, high-standard research, replicated with positive outcomes and backed by their effects on student outcomes) for evidence-based practices (EBPs) is limited. Research that focuses on students who are DWD, particularly using evidence-based teaching practices, is insufficient. However, it has been noted that there has been an increase in the number of published research articles specifically related to students who are DWD in the past decade [9].

Evidence-Based Practices

Borders and colleagues [20,21] stressed the importance of using strong instructional strategies when teaching DWD students. However, there exist few evidence-based practices (EBPs) in the field of Deaf Education from which teachers of the deaf and hard of hearing (TODHH) can draw. For this reason, the authors recommend that educators explore teaching approaches from the field of special education as a whole as they seek to identify the strategies that work best with their student who is DWD. Specifically, the authors present structure, systematic instruction, least-to-most prompting, simultaneous prompting, constant time delay (teacher prompting the student and allowing a specific amount of time for the student to respond before providing additional support), and forward/backward chaining (breaking complex behaviors or tasks into smaller sequential steps) as strategies that could be successful when working with this population. Borders and Probst [22] also suggest using video modeling, as this strategy has been shown to decrease the language demands for concept development and can also target language objectives. Using various communication techniques (e.g., acting, miming, picture supports, full ASL sign), video modeling has been shown to be effective when working with d/DHH students.

Some other literature has suggested a handful of promising teaching methods and strategies for students who are DWD. Planning educational experiences for these students can include, but are not limited to, making materials, identifying the core concepts and ways to deliver those in accessible ways, providing necessary time and opportunities for building foundational skills and background knowledge, and generalization of concepts across environments [21]. All of these things must be thoughtfully organized so as to be addressed within the constraints of the educational day. McBride and Goedeke [23] described an approach they used from the Human Development Institute at the University of Kentucky [24], which included a four-step process to modify the curriculum for students who are DWD. The steps used were: “1. Identify and link to the appropriate standards. 2. Define the outcomes of instruction. 3. Identify the instructional activities. 4. Target specific objectives from the Individualized Education Program (IEP)” (p. 8). The researchers report that these steps enabled teachers to scrutinize educational standards, refine student outcomes, and implement best practices while creating educational opportunities (e.g., project-based learning, accessing background knowledge, scaffolding instruction, group work, etc.) for DWD students. These steps are general enough that they can be applied across the general education curriculum and a student’s IEP while incorporating instructional strategies that work best for the learner’s educational needs.

Another critical issue associated with EBP related to individuals from diverse backgrounds, like those who are DWD, is illuminated by Cawthon and Garberoglio [25]. These authors point out that the “evidence in evidence-based practices is not typically developed, validated, or reviewed within frameworks that are culturally responsive to diverse populations, including deaf students” (p. 346). They use the What Works Clearinghouse (WWC) as an example to illustrate this. The EBPs outlined on the WWC website do not include any summaries of research specific to deaf students or, for the purposes of this article, students who are DWD. Overall, there is a shortage of research in deaf education. Specifically, research related to practices that can be classified as EBPs that can be used to increase the outcomes of learners who are DWD. Furthermore, many of the studies conducted with students who are d/Dhh often exclude students with additional disabilities. Of the few studies that do exist and focus on students who are DWD, most are not replicated or generalizable to other DWD students.

The unique needs and challenges encountered by students who are DWD with grade-level learning standards and expectations are similarly felt by their educators. Education professionals are being held to increasingly higher standards, including testing, alignment with content standards, and access to the general education curriculum for all students [26], including those with the most complex needs. As a result, teaching methodologies have had to be refined and implemented to meet these students’ needs. Many times, educational resources are developed based on research. In short, with a dearth of research, a similar lack of resources is available to educational professionals.

5. Teacher Training

Researchers have reiterated that in order to effectively work with DWD students, teachers need specific knowledge and skills [27]. However, surveys of teachers, administrators, and faculty in d/Dhh teacher preparation programs over more than 20 years indicate many teachers of students who are d/Dhh (TODHH) do not feel comfortable or prepared to work with DWD students [16,27,28,29]. Guardino [22] asserts,

among the reasons for the lack of course work in postsecondary programs are that (a) faculty do not feel prepared to teach on the subject because they lack expertise, (b) programs of study are already full and do not allow for additional coursework, and (c) faculty lack the time and resources to infuse the content into their courses.

(p. 423)

However, authorized teacher preparation programs should follow the standards and guidelines provided by the National Association of State Directors of Special Education [30] and the Council of Exception Children (CEC)/Council on the Education of the Deaf (CED) [31], which have outlined “competencies necessary to be a highly effective teacher, including those skills necessary to work with students who are DWD” [27] (p. 424).

Aggravating and compounding this lack of training is a severe shortage of teachers of students who are d/Dhh, including those who are DWD. Following trends across all teaching related fields, the American Association for Employment in Education (AAEE) [32] recently reported “considerable teacher shortages” (4.45/5) for “Special Education: Hearing Impaired Teachers”. There is both a shortage of professionals to fill available positions and a shortage of positions to meet the growing demand for the future. Fischgrund and Tucker [33] predicted at least 500 TODHH would be needed within three years in Schools for the Deaf in the United States. They also indicated that this number greatly underestimated the total number of teachers needed since a large majority of d/Dhh students are educated in general education-inclusive environments in school districts around the country. Furthermore,

The Council on Education of the Deaf (CED) noted in a February 2019 communication that the nation has experienced a decline in qualified teachers of the deaf. The largest group of deaf educator graduates was in 1985 and numbered 1680. This number has consistently declined over the years with only 737 graduates in 2009, and 450 in 2018 and 2019. It is estimated that 300 will graduate in 2020. With well-qualified deaf educators in short supply and high demand across the nation, a shortage that is expected to continue to worsen in coming years, competition for these valuable teachers is great.

[34] (p. 51)

This drop in the number of graduates is partly due to the fact that the number of d/Dhh teacher preparation programs has declined in recent years [28]. There are currently 56 university programs that offer teacher preparation programs in the area of d/Dhh in the United States, down from 63 programs in 2018. The Council on Education of the Deaf [31] calls this a national crisis. Other potential reasons for the current shortage identified by Luft and her colleagues [35] include inconsistent state licensing/certification policies and procedures and high retirement rates of current educators.

Peyton and Acosta [36] corroborated these findings for the field of special education in general, indicating “teacher education programs have recently been seeing declining numbers of graduates, signaling inevitable teacher shortages” (p. 21). They further explain teacher shortage challenges as “quality shortages” where schools hire teachers in a temporary capacity when they have not yet met the requirements for the teaching license. They maintain that these shortages imperil the opportunity for students to receive appropriate services.

Teacher shortages also impact teacher retention. In a study looking at special education teacher shortages, Peyton and Acosta [30] found that teachers in states with high levels of teacher shortages had higher caseloads to manage and were more likely to either leave their current position for a different position or leave the profession altogether, unintentionally creating “vacancies that are more likely to be filled by less qualified individuals’’ (p. 22). CED [31] further explains, “an important instruction impact is seen in the increasing ratios of D/deaf and hard-of-hearing students to teachers. In 1976, this ratio was at its lowest of 30:1 but has increased every year thereafter, with the most recent data (2006) showing a ratio of 56:1 [37]. Given the current number of D/dhh students and the number of graduates being only 54% to 43% of the 1994 levels, these ratios could be expected to rise to 144:1 this year” (p. 1).

6. Identification Complications

Early hearing detection and intervention have been shown to positively impact outcomes for d/Dhh children and for children with disabilities. However, for infants who are DWD, medical complications and developmental delays may impede the age of hearing loss identification [38]. In addition, the “identification of disabilities in children who are DHH is challenging, and hence, diagnosis and subsequent early intervention frequently occur at an older age than children who are DHH alone” [1] (p. 134.) Furthermore, medical conditions and syndromes identified after the newborn period (e.g., ASD) may still impact newborn hearing screening results and follow-up care. Risk factors often associated with hearing loss may overlap with risk factors for developmental delay, particularly genetic syndromes, prematurity, and ASD. Consequently, hearing loss may be identified first through newborn hearing screening, with the recognition and identification of the co-occurring disability significantly later. Or on the other hand, screening and identification of hearing loss can be delayed for children who have complex medical conditions. Either way, the comorbidity complications may affect the overall development of the infant/toddler in all developmental domains, including language, cognition, and social development.

7. Challenges and Opportunities for 21st-Century Professionals

Students who are DWD represent a diverse subgroup of DHH school-aged children and youth. Professionals need to have the requisite knowledge and skills needed to ensure that all children have opportunities to learn and achieve. The challenge of providing sensory access to the environment through the use of technology (e.g., hearing aids, cochlear implants, eyeglasses, CCTVs, magnifiers, etc.) is one on which educators of children who are DWD often spend much time and effort. Addressing access needs is a critical foundation upon which educators must build programming. The following section will outline current challenges with suggestions for professionals to create positive opportunities for DWD students.

8. Communication and Language

Students who are DWD have complex communication needs that vary and may change based on the setting, peers, family, and over time. Depending on the combination of disabilities, students who are DWD may exhibit a wide range of receptive and expressive communication modalities and combinations, including spoken language, signed language, and alternative and augmentative communication systems. It has been well documented that in spite of technological advances and a renewed focus on natural signed languages such as American Sign Language (ASL), many children who are d/Dhh are delayed in language development. Not surprisingly then, communication and language development are even more likely to be delayed in children who are DWD [39]. While there is scant evidence that one modality is better than another, a substantial body of research supports early meaningful language interactions regardless of the modality. Furthermore, a primary goal of Family-Centered Early Intervention supports the premise that families make informed choices when implementing communication options that meet their needs and that communication building blocks may change and expand over time as the child develops and the needs of the family and child change [40]. Parents and caregivers have indicated that choosing a communication option is one of the most challenging decisions they make once they find out their child has a hearing loss, and often occurs before families are “fully knowledgeable and/or emotionally ready” [41] (p. 243). However, research has substantiated that high levels of family involvement significantly impact overall language development [42]; therefore, families should explore all communication options and follow their child’s lead showing what communication options work best.

Parents of children who are DWD must consider additional factors specific to their disability when considering language and communication options. It has been documented that children who are DWD have complex language needs and may demonstrate delayed language in both visual and auditory modalities [1]. Examples include oral-motor challenges which may impact speech production, fine motor control challenges impacting the use of sign language, difficulty with joint attention, social communication, and processing time for children with low cognitive skills. In some cases, children using sign language may need signs to be adapted [1]. In other cases, Augmentative and Alternative Communication (AAC) devices should be considered to support communication [15]. AACs are communication devices, systems, tools, and strategies that support communication for those who have difficulties using speech or sign. AAC devices use pictures or symbols to represent words that students can use to create phrases or sentences to communicate nonverbally. AACs can range from low-tech to high-tech with both physical (communication boards, pictures, objects) or digital (iPad/ tablet, computer software programs) options.

While students who are DWD use a wide range of communication and language options, there is limited existing research surrounding the benefits and outcomes of communication choices. There is some emerging research regarding strategies for using visual language, outcomes of cochlear implantation habilitation, and the use of AAC devices specific to DWD students. However, more research is needed in each of these areas as there are varied and sometimes conflicting outcomes and research conclusions [1,43].

In considering students’ strengths and areas of need, a TODHH should be involved to assess the student’s communication skills and abilities and to ensure that communication access is at the core of the IEP [44]. Specifically, the IEP team must consider:

(1) the child’s language and communication needs; (2) opportunities for direct communication with peers and professional personnel in the child’s language and communication mode; (3) academic level; (4) full range of needs, including opportunities for direct instruction in the child’s language and communication mode; … and (5) whether the child needs assistive technology devices and services.

[45] (p. 28)

Teachers and professionals should prioritize language and communication needs since this impacts all other areas of development. Professionals [46] and parent support groups (e.g., Hand and Voices) [47] advocate that schools use a Communication Plan as a tool to guide and address each student’s unique language and communication abilities and ensure their needs are met and their strengths are identified. The Communication Plan identifies the student’s language and communication preferences and links communication to the other aspects of the IEP, including the five components listed above [48].

9. Assessment

As previously stated, disabilities are more likely to be identified later in a child with hearing loss than in a child without hearing loss [48]. Moreover, assessment procedures can often result in misidentification for children who are DWD. For example, because communication and social skills are affected in both ASD and d/Dhh, ASD might be missed or misdiagnosed in a child who is deaf or vice versa.

There are multiple challenges when considering the assessment of DWD students. Nelson and Bruce [1] identified three categories that challenge identification and impact educational planning;

(a) Diagnostic overshadowing, (b) difficulties obtaining accurate auditory assessment information, and (c) limitations inherent in existing assessment instruments. Diagnostic overshadowing occurs when two disabilities share common indicators and the first identified or the most prominent “overshadows” the identification of communication, or cognitive difficulties, is unable to reliably indicate responses to auditory stimuli. Therefore, determination of degree and type of hearing loss can be inaccurate. Finally, available assessment tools for disabilities are often not designed to accommodate for the complex needs of children who are DWD and in fact, some assessment instruments specifically advise that instruments not be used to evaluate children with a hearing loss (e.g., the Autism Diagnostic Observation Schedule [ADOS]).

(p. 134)

These challenges increase the likelihood that a child might be misidentified and/or not receive appropriate educational planning to meet his/her unique needs. Early interventionists can provide support to families who have concerns or who have a child identified as DWD during the early years by monitoring developmental milestones, watching out for “red flags” [49], and referring to specialists as appropriate.

Few assessment instruments have been designed specifically for students with hearing loss, including DWD. When assessing school age students with co-occurring disabilities, evaluators must consider the student’s communication modalities and the limitations of standardized assessments with students outside of the norming population. Cawthon [50] stated, “designing assessments and tests is one of the more challenging aspects of creating an accessible learning environment for students who are deaf or hard of hearing (DHH), particularly for deaf students with a disability (DWD)” (p. 385) She continues that educators should be cautious in making assumptions about what students are learning, both in general education settings and in pull-out or self-contained settings and recognize that DWD students may not have the same content depth and breadth acquired by the general population of students. Furthermore, although students with disabilities have allowable accommodations to make assessments more accessible, “these accommodations do not compensate for linguistic or experiential gaps” [46] (p. 139) often experienced by DWD students.

Borders and her colleagues [51] asserted, “assessment of educational skills in D/HH students can be complicated. The impact of communication, language, reading, and writing delays [52,53,54] can compromise the accuracy of assessments administered and conclusions drawn” (p. 83). The results of these assessments have an impact on the placement of the student and, subsequently, access to the general education curriculum.

10. Least Restrictive Environment (LRE) and Instructional Strategies

The Individuals with Disabilities Education Act (IDEA) in the United States oversees state and public agencies that provide early intervention, special education, and related services to all children who are eligible. This law also ensures that all students have an equal opportunity to full participation in a free and appropriate public education (FAPE) [55] and further recognizes that high expectations are needed for students with disabilities to “meet developmental goals and, to the maximum extent possible, the challenging expectations that have been established for all children” [56]. To further clarify this, the Elementary and Secondary Education Act (ESEA; 1965) specifically stated that school districts and educators must provide all students with disabilities, including learners with significant support needs, a free, appropriate, and equal opportunity to acquire age-appropriate academic content and meet challenging expectations and must be included in state assessments that address a state’s academic content and achievement standards [57,58]. All public schools and their students are subject to these laws.

Every student with a disability is entitled to a range of placement options. Deciding on the placement that is best for providing the student with the least restrictive environment (LRE) is the job of the IEP team, including the student, when appropriate, and the family. Specific to DWD students, there is scant research about placement. Borders and colleagues [11] reported that placement decisions, primarily those relative to services, teaching strategies, and accommodations, for these students might be impacted by the educational label chosen by the IEP team. When evaluating placement, research from the field of autism has indicated that these decisions are based on aspects such as disability and the intensity of support need [59], the impact of disability on communication [60], behavior [61], social skills [62], teacher training [63], and the availability of professionals to provide appropriate services [64].

LRE, as required by federal mandate through IDEA, is often misunderstood for students who have hearing differences. The intent of LRE is, to the maximum extent possible, to educate students with disabilities with their typically developing peers. However, the IDEA is very clear that placement decisions should be made by the IEP team accounting for a child’s unique needs. Specifically, for d/Dhh students, including DWD, the setting must meet the child’s communication needs, which might include placement outside of the general education setting. As stated in the Special Factors section of the IDEA, Part B, the IEP Team shall,

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 communication with peers and professional personnel in the child’s language and communication mode, academic level, and the full range of needs, including opportunities for direct instruction in the child’s language and communication mode.

[55]

If the team determines that there are communication needs, these must be addressed in the IEP including providing appropriate accommodations to meet the communication needs. Accommodations might include supplementary aids and services and assistive technology. Furthermore, the LRE must provide access to the general education curriculum with appropriate accommodations that consider the child’s unique learning and communication needs. Any curriculum that is tied to a state’s academic standards and used by all students in the same grade is referred to as the general education curriculum. Therefore, all students who are DWD must be provided access to the general education curriculum for their grade level.

IEP teams should investigate placement options across the full continuum for DWD students. With the increased complexity of learning needs for students who are DWD, educational teams strive to find the most effective educational placement that will also provide them the best access to the general education curriculum. Over the past several years, educational teams have increasingly chosen general education settings for students who are DWD. In fact, as of 2013 and continuing forward, it has been noted that the majority of students who are DWD (with fewer of those who were diagnosed with ASD or ID in these settings) were placed in inclusive settings [10,27,57]. The population of DWD students in inclusive settings might most often be served by an itinerant teacher. Pedersen and Anderson [65] reported that 30% of d/Dhh itinerant teachers’ caseloads consisted of DWD, and these teachers indicated they were prepared but not fully prepared to meet the needs of these students.

11. General Education Access

The word access means to obtain information. For educators responsible for providing access to the general education curriculum for DWD students, access to education, let alone the general education curriculum, has long presented difficulties. However, purposeful inclusion in general education is one facet that contributes to successful educational outcomes [19,66]. In fact, schools today are experiencing more accountability for teachers, high-stakes assessments, and alignment to learning standards while providing programming for all students that provides access to the general education curriculum. To provide access to the general education curriculum when designing a student’s IEP, especially for a DWD student, the team must begin by determining the associated disabilities and the impact of those on the student’s learning. By doing this, the team is better able to create an educational plan, interventions, and curriculum that addresses the student’s unique needs [67]. Keeping access in mind, there are instructional strategies that can prove helpful to educators.

12. Instructional Strategies

Regardless of the educational placement chosen for the DWD student, it is vital to present instruction through multiple means when teaching d/Dhh students [22], including those who are DWD. The Placement and Readiness Checklists for Students who are Deaf and Hard of Hearing (PARC) [68] are designed to aid IEP teams in planning the placement and support needs of D/HH students based on language needs. With appropriate planning, IEP teams can design an educational program that provides the support necessary for students to obtain access to the general education curriculum and be meaningfully included in academic environments.

In 2015, Yudin and Musgrove [69] released a “dear colleague” letter reinforcing the importance of holding high expectations for all students, including those with disabilities. They reiterated that students with disabilities should have “meaningful access to a State’s academic content standards” (p. 1) and that the IEP must be aligned to the grade-level standards “for the grade in which the child is enrolled” (p. 1). However, access to the general education curriculum has historically been challenging for DWD students. Using multiple means and presentations of information is one way to provide the access needed for DWD students. Some researchers have suggested the theoretical framework of Universal Design for Learning (UDL) as one way to provide access and engagement for students with disabilities in inclusive settings [9,22,70]. Using the UDL framework, teachers can customize goals, evaluations, teaching strategies, and materials to the needs of the student [71].

The ten most frequently cited interventions used with d/DHH students include (1) independent reading, (2) use of technology, (3) phonemic awareness and phonics, (4) metacognitive reading strategies, (5) writing to promote reading, (6) reading in content areas, (7) shared reading and writing, (8) semantic approaches to vocabulary, (9) morpho-graphemic approaches to vocabulary, and (10) fluency interventions [72]. While some of these approaches could be successful with DWD students, there may be the need to incorporate extra support. For example, one research-based literacy method for shared reading that was developed for use with school-aged students with significant cognitive disabilities, including those who are d/DHH, visually impaired, and deafblind, is the Tar Heel Shared Reader (THSR) [73]. The THSR is for use with students whose comprehension level is not above second grade and does not read connected text.

DWD learners profit when information is presented many times and offered in diverse ways. Finding appropriate strategies to accomplish this can be difficult for some TODHHs, especially when their students experience the multiplicative impact of additional disabilities. One way to engage students in learning experiences and increase the chances of retention of information is to incorporate more of their senses in an impactful way. Atkinson [74] shares that deeper learning experiences can be achieved through visual environments that stimulate symbolic emotional and intellectual scenarios and, in turn, initiate responses in the student.

Accessibility can present a dilemma for some educators; however, technology can provide some innovative solutions. Using technology to meet the accessibility needs of DWD students allows them to engage in various ways. Borders and colleagues [22] posit that technological tools and apps can empower student autonomy and independence while also participating more fully in the learning environment. For instance, educators can teach students how to use the question-and-answer feature in Google Slides when conducting class presentations. This feature allows audience members to access a page where they can craft questions for the presenter. Not only is this one way to increase engagement, but it also allows students who may struggle with verbal communication the ability to participate in the discussion.

13. Lifespan Perspective/Person-Centered Planning (PCP)

In 2016, Borders and colleagues [20] proposed a decision-making framework for educational decision making that could be used by IEP teams providing services to DWD students. Using the lifespan perspective (deliberately using routines to shape behaviors in ways that will be understood and socially acceptable from childhood through adulthood), the authors suggest that goals should be created using person-centered planning (PCP), focusing on the student’s stated needs, strengths, and interests. The authors then presented educational programming for DWD students in three distinct categories: developmental approaches, access, and instructional approaches.

When making decisions about a student’s educational program, the team must consider the child in a way that focuses on the current situation and what a good life would look like for them. This requires the team to gather information about the student’s abilities, needs, and interests while also working with the student and their family to develop a vision for their future. While PCP has long been used for transition planning beginning at age 14, many professionals contend that this approach should begin much earlier. Some supports needed for a successful PCP include but are not limited to sufficient time for collaboration among education professionals, the student, the family, community members and others, administrative support, clearly incorporating the PCP findings into the IEP, and, at times, financial investment.

One tool that has been found to be very helpful for teams was developed at the University of Missouri, Kansas City, and is called Charting the LifeCourse (CtLC) [75]. This framework uses collaborative engagement to help anyone, regardless of age and ability, and their families visualize, plan for, and identify supports to help the individual move in a positive direction to achieve their desired life outcomes [24]. Utilizing this framework across the lifespan encourages independence and self-determination, high expectations, and community engagement and allows the individual and family to access the supports they need at each stage of their life while navigating through life stages.

14. Collaboration with Professionals

Students who are DWD may require specialized support throughout their educational journey. The IEP team should consist of a group of specialized teachers, professionals, and support staff who can contribute to the multidisciplinary team [9]. Special Education Teachers, TODHHs, and General Education Teachers should work together to assess students’ needs, establish high-quality goals, instruct using the appropriate curriculum, provide appropriate accommodations and modifications, and support students’ overall learning and development. Related services personnel (e.g., Speech Language Pathologist (SLP), Occupational Therapist (OT), Behavior Specialist, etc.) have discipline-specific expertise that is different from teachers. These individuals might work directly with an individual student or consult with team members who then provide assistance during educational activities [76].

In support of collaboration, Guardino [27] found that participants in her study turned to other professionals who had expertise in working with students who are DWD when they lacked sufficient knowledge or skills in “academic, social, and behavioral intervention” (p. 423). She also found teachers turned to the Internet to find information, including “resources, virtual communities, and forums to discuss and share ideas that can help them serve students who are DWD” (p. 423).

15. Conclusions

The purpose of this article was to explore what we currently know about DWD students, and to identify the knowledge and skills needed by teachers in the 21st century to meet the needs of these students and their families. What we have found is the population of DWD students is diverse and growing. We also discovered that researchers and university teaching training programs have neglected this population of students [27]. It has been well documented that the effects of a disability coupled with hearing loss create unique educational needs that may differ from those displayed by d/Dhh students without disabilities [1,67].

We urge scholars to not only conduct research specific to DWD students but also to include this population in the research they conduct in general with students who are d/Dhh. Despite well-intentioned efforts, students who are DWD are often excluded from eligibility criteria in research studies. Furthermore, scholars are urged to collaborate with professionals in related fields to better understand the needs of the specific disability categories. More focused attention to DWD will increase the current foundational knowledge and build a body of evidence-based practices and communication/language interventions and begin to systematically identify how to overcome barriers and challenges and identify EBPs to provide a high-quality educational experience for all children with hearing loss, regardless of disability. In the meantime, Borders and colleagues [21] suggest we look to and collaborate with professionals in adjacent fields to discover practices already in place for students with disabilities that may be effective for DWD students. Increased research opportunities, coupled with a focused multidisciplinary approach will allow EBPs to emerge. Teachers can then implement these instructional strategies with students who are DWD.

In turn, university teacher preparation programs must make a concerted effort to include content, assignments, and field-based practicum experiences for pre-service professionals related to working with students who are DWD [27]. These topics should be assembled from the appropriate d/Dhh Specialty Set of standards approved by national accrediting bodies [77] and individual state licensure standards.

Finally, school, district, and program administrators should work cooperatively with state directors of special education and university programs to incentivize opportunities [30] for preservice teachers to enter the field of education for students who are d/Dhh. The current extreme shortages and projected shortages of qualified/credentialed TODHH are alarming. TODHH is vital for the appropriate evaluation, educational programming and planning, student-centered instruction [44], and ensuring of communication access for d/Dhh students, including DWD.

Because of dissimilarities in identification and severity of the numerous accompanying disabilities within the population of students who are DWD, there is not a one-size fits all answer. Rather, professionals, including teachers and support staff, must recognize both the strengths and the needs of each student individually. This process will provide opportunities for students to be educated in an appropriate setting, with the necessary modifications and accommodations to access the general education and specialized curriculums. Ultimately, we know that “Given effective educational planning, students who are deaf or hard of hearing, including those who are deaf with additional disabilities, can attain high levels of achievement” [30] (p. 29).

Author Contributions

All authors contributed equally to the conceptualization and writing of this paper. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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