8 Visual and Hearing Impairments
We rely on our five senses to take in and interpret information about the world. A disorder affecting one or more of the senses can significantly impact a child’s ability to learn and to interact with others and his environment. Disabilities that involve vision or hearing are uncommon and considered low-incidence disabilities. Generally, several professionals work together to design the individualized interventions a child needs, and although there is a range of educational settings for children with sensory impairments, many are successfully included in general education settings.
Visual Impairments: Blindness and Low Vision
Tirzah was born with no useful vision, but that has never slowed her down. Now in second grade, she loves to be part of the classroom lessons, especially when Mrs. Freeman reads wonderful books out loud and everyone talks about them. Tirzah has always enjoyed science, too—until this year. Last year her teacher had the students do lots of hands-on experiments. Tirzah could hold the materials and feel the changes that occurred, and she relished these activities.
Mrs. Freeman does not do experiments like this. Most of the time, the students just watch her do the experiments and then they draw pictures of what happened. Tirzah feels left out. She does not know what is happening during the experiments until Mrs. Freeman tells her. Instead of drawing a picture, Tirzah types out her answers on a worksheet. When she asks the teacher if there are some experiments she could be a part of, Mrs. Freeman says that she is sorry, but the experiments aren’t safe for a child who is blind. This makes Tirzah very upset.
Tirzah’s mom, wanting her daughter to be more included in valuable science instruction, meets with the district’s science supervisor, Mr. Antonakis, to see if the school can find ways to have Tirzah participate more actively. Mr. Antonakis does some research and finds the Perkins School for the Blind’s website, which offers accessible science activities and dozens of ideas on how to make science come alive. Together, he, Mrs. Freeman, and the teacher of the visually impaired who works with Tirzah a few times each week review the types of experiments that Tirzah and the rest of the students could all participate in. With some coaching from the teacher of the visually impaired, Mrs. Freeman begins to feel comfortable with helping Tirzah be more actively involved.
Vision helps children understand and learn about the environment they live in, the people they interact with, and the language they hear. Because so much of learning in the early years occurs visually, a child with impaired vision requires modifications and adaptations to both the environment and instruction to learn at the same pace as her peers.
A Closer Look at Some Causes of Visual Impairments
In addition to refractive vision problems, other conditions can impact young children’s vision and impede their learning. These include strabismus, a condition in which the muscles surrounding the eyes prevent both eyes from being able to look at the same thing at the same time, significantly affecting a child’s depth perception (Donahue et al. 2014). Retinopathy of prematurity is a disease that impacts the blood vessels in the eye and occurs in some premature babies who received oxygen therapy to develop their lungs while in neonatal intensive care. It can lead to permanent blindness (AAPOS 2016).
Cortical visual impairment (CVI) is caused by a problem in the brain with processing what the eye sees, rather than a problem in the eye itself. Children with CVI may have difficulty attending to visual stimuli, delayed responses to what they see, and/or better vision when they look at objects that are moving (or appear to be, like sparkly objects). The condition does not generally lead to total blindness. CVI can happen from an injury at birth, including a lack of oxygen in the blood or a lack of blood to the brain. Traumatic brain injuries, strokes, and infections of the central nervous system such as meningitis and encephalitis can also cause CVI (Roman-Lantzy 2007).
What Are Visual Impairments?
The term visual impairment is broad and describes the effects of various eye disorders. The eyes and the brain work together to help an individual see, and if parts of the eyes are damaged or not working correctly, or the eyes and the brain do not communicate properly, vision may be impaired. A child with a visual impairment may have partial vision or none at all.
According to the National Eye Institute (NEI 2017), the most common vision problems are refractive errors, in which the shape of the eye interferes with the ability to focus. These errors can result in such common conditions as nearsightedness, farsightedness, astigmatism, and presbyopia. Refractive errors are usually correctable with eyeglasses, contact lenses, or surgery. Other, more serious conditions may involve the eye muscles, blood vessels in the eyes, or damage in an area of the brain necessary for proper sight.
Vision impairments can result in a child having low vision, which means a visual acuity of 20/70 or worse (20/20 is considered perfect vision) that cannot be corrected (Kellogg Eye Center 2017). For example, a child may see only light, shadows, and indistinct shapes. Legal blindness refers to an acuity of 20/200. Most children with a visual impairment have some useful vision; only a small percentage of individuals experience total blindness.
Possible Reasons for Visual Impairments
Children may be born with impaired sight or lose vision later on. Hereditary conditions, diseases, illnesses, neurological conditions, and accidents can all cause loss of vision in children.
Impact of Visual Impairments on Development and Learning
Having a visual disorder affects a wide range of skills—navigating the environment, detecting and avoiding hazards, performing daily activities, relating to other people, and learning language, concepts, and what the world is like. Limited vision affects a child’s ability to fully experience the world and build concrete knowledge, and since children learn many self-help skills through observation, a child with impaired vision may experience delays in learning skills like eating, dressing, and personal hygiene.
Visual impairments also impact social development. Limited vision affects a child’s ability to understand nonverbal clues, such as when it is his turn to talk. Without eye contact, a child may appear disinterested in a conversation, which affects his ability to sustain interactions with other people.
Many children with visual impairments do not have learning disabilities or other disabilities in addition to their vision impairment. Many learn the same academic skills as their sighted peers, but they learn them in adapted ways. Some children are able to use what vision they have to learn, perhaps aided by magnifiers, while others rely on their other senses as well as additional aids such as technology.
Children with vision impairments need specific interventions. Being included in the classroom with their peers is very common, and ideally every child with a visual disability will have the assistance of a trained teacher of the visually impaired who visits the classroom to help the teacher adapt and modify activities and the environment and understand the tools the child is using. This professional often provides some direct instruction to the child as well.
Identifying Visual Impairments
These signs may indicate that a child is having difficulty seeing (AAP 2016; NCBDDD 2017; The Vision Council 2017):
» Squinting
» Closing or covering one eye to look at something
» Holding objects close to her face, like books or screens
» Frequently tilting his head to one side
» Rubbing her eyes repeatedly
» Experiencing redness or tearing in one or both eyes
» Blinking excessively
» Being sensitive to light
» Complaining of blurriness or being out of sorts when looking at things closely for a period of time
» Having eyes that look crossed, turn out or in, don’t focus together, flutter, or are watery
In babies older than 4 months, adults should watch for difficulty tracking objects across the line of sight or inability to make steady eye contact (Kirkendoll 2016). Drifting or crossed eyes beyond this age also may indicate a visual impairment. All children should have their vision checked early—as a newborn and at well-baby visits. In addition, if parents or teachers suspect a child may not be seeing properly, a visit to a pediatric ophthalmologist should be scheduled. Detecting a problem early increases the chances of correction and helps to avoid further issues, and early intervention for more serious problems is vital.
Strategies for the Classroom
Each state has an agency that assists families and schools in identifying the educational services each child needs, including a teacher of the visually impaired. This professional works with children on specific vision-related skills (AFB 2017a; AFB 2017b):
» Orientation and mobility (O&M) skills. Children with vision impairments need to learn how to get around different (and unknown) environments safely and independently.
» Assistive technology skills. Many children with visual impairments need to access computers through means other than a mouse or touchpad. Assistive technologies like braille-adapted keyboards enable children to use computers independently. Voice recognition software and screen readers—software that converts text displayed on a computer screen to speech or a braille display—are commonly used by individuals with vision impairments.
» Braille. Children with significant vision impairments learn to read and write using braille, a system of raised dots that are read with the fingers.
In addition to specific skills addressed by the teacher of the visually impaired, everyday adaptations and modifications can support children with visual impairments in the classroom.
Encourage Independence
» Watch for well-meaning adults and peers who seem overprotective of a child with impaired vision or who join the child for activities or social situations because they want to “help” her. Keep a watchful eye on the child with a visual impairment, but avoid offering more assistance than she needs during classroom activities and play. Resist the urge to do things for her because you fear it will be too difficult or take too long.
» Let the child explore the environment and navigate to the places he wants to go. Do not always have someone else lead him. This is especially important as the child gets older and starts to use new tools for mobility, such as a cane or a guide dog.
» Keep the environment clean and organized. Provide enough room for the child to navigate, and make sure materials are easy to locate.
» Have high expectations for a child with a visual impairment, just as you would for any child. Do not treat her differently or ignore challenging behavior.
» Facilitate friendships between a child with a visual impairment and his peers. Partner children for activities. Children without disabilities take their cues from you on how to act toward a child with a disability. If you are accepting, they will be too.
» Teach an older child how to navigate a new environment before school starts or during times when other students are not there.
Modify the Environment
» Look at the labels in your environment. Add something tactile in addition to print and braille. For example, have a special texture such as sandpaper on the labels to indicate that these are materials the child can handle, and use a contrasting texture, like a smooth and silky fabric, to indicate the location of materials that are to be used only by the teacher. Be sure the child learns what these tactile cues mean.
» Provide objects that are brightly colored or on high-contrast backgrounds.
» Provide dress-up materials that are easy for a child with a vision disability to manipulate. For clothing that has small hooks and eyes, add other ways to fasten them, such as Velcro.
» Add textures to finger paints, and put the child’s paper on a tray with sides or inside a shirt box so he can feel the boundaries.
» Use textures to create letters, numbers, and words the child can trace and feel. Use glue or cut the shapes from sponge or felt.
» Keep in mind that real objects are always better than plastic replicas. Offer real materials that relate to the content children are learning and that they can touch, smell, feel, and taste. For younger children, provide food containers for dramatic play that are the real size and weight instead of plastic so that they can touch and explore. Provide collections of natural objects, such as shells and bird nests.
» Have braille books and story props along with picture books.
» Encourage art exploration. Include many 3-D art materials like foam, cotton balls, and wood scraps for the child to create with.
» Make sure the environment in the primary grade classroom includes signage with braille. A child should learn to read the signs in the environment from an early age.
Modify Activities and Lessons
» When you present something visually, use an object the child with a visual impairment can touch and manipulate or that produces a sound that brings meaning to the activity. If you are demonstrating something, try to position yourself near the child so she can better see and hear what you are doing.
» Verbalize everything. Use all children’s names rather than just nodding at or pointing to them. Whatever you write on a chart or a child’s paper, verbalize as you write it. Remember the universal design principles discussed in Chapter 3? This strategy is a good example—it benefits all children.
» Use clear directions. Phrases like “over here” are confusing to a child with a vision disability.
» Make activities and lessons active. Instead of learning about the farm only through books and videos, take the class to a farm to experience the animals and planting or harvesting techniques. Again, all children benefit from these hands-on, minds-on experiences.
» Give the child extra time to explore materials and to complete and practice lessons, particularly when he is learning something new or still learning a technique, like using a braille writer. With time and proper support, most children with visual impairments will eventually be able to keep to the same pace as other children.
» As the child gets older, make sure as much of her work as possible is done using braille technology. Braille readers and writers can be used with children starting in the primary grades. A teacher of the visually impaired will teach braille, but every teacher can make sure the child uses it each day.
Visual Impairments Summary
While many children with visual impairments can learn academic skills along with their sighted peers, they need adaptations to do so. They also require specific interventions to learn how to move around safely and independently, effectively use the vision they have, and use assistive technologies.
Hearing Impairments
Everyone agrees that Cèsar is such an easy baby. At 2 months old, he sleeps right through the dog barking at the mail carrier and his two siblings running and yelling while they play. While his mother, Eva, is happy that Cèsar is calm most of the day, she has a very hard time soothing him when he is fussy. He doesn’t seem to respond to her whispers in his ears or to the musical mobile in his room that his siblings had loved. Nothing seems to pacify him.
Eva is about to go back to work full-time, and she hopes the child care center that Cèsar’s siblings attended will help her figure out how to soothe him. The caregivers there are the best at figuring out what works and what doesn’t for babies. They helped Eva so much with her other children when they were young.
Cèsar’s caregiver, Anna, starts to notice some things about his development. He isn’t starting to “talk” (making vowel sounds like oh and ah) yet when she plays with him, and he doesn’t seem to react to familiar voices in the classroom.
Anna talks to Eva about her concerns and suggests that she have the pediatrician check Cèsar’s hearing at the next visit. At the doctor’s office, Eva is shocked to learn that Cèsar has significant hearing loss in both ears. At the pediatrician’s recommendation, she takes her son to an audiologist who specializes in treating infants with hearing loss, and Cèsar is fitted with hearing aids. It takes a long time for him to get used to these, and he often tries to pull them out like some babies yank off hats or socks. The early interventionist who has begun to work with the family advises both Eva and Anna to start by putting the hearing aids in only during times Cèsar has direct interaction with them, and then take them out for a while. As Cèsar slowly adjusts to all of the new sounds he is hearing, he seems to really enjoy anything that makes noise, including rattles, bells, and his mom’s voice.
Because language, speech, and hearing are all interconnected, identifying hearing loss early is important. Speech and language skills develop rapidly before the age of 3, and when a hearing loss is not identified, children will be delayed in developing these skills (March of Dimes 2014a). The CDC recommends that every newborn be screened for hearing loss as early as possible, usually before they leave the hospital (2015c). Professionals such as audiologists, speech-language therapists, and sign language specialists work closely with teachers to maximize a child’s hearing, communication, and learning.
What Are Hearing Impairments?
A hearing impairment is a partial or total inability to hear. The CDC (2015c) uses the term hearing loss to describe any degree of hearing impairment, including deafness. IDEA defines hearing impairment and deafness as separate terms and eligibility categories.
Hearing impairments range from mild, where a person might hear some sounds but have difficulty differentiating speech in noisy environments, to profound. Individuals with profound hearing loss may be able to detect and feel the vibrations of some very loud sounds, but they cannot hear any speech. A hearing impairment to this degree is considered deafness. Depending on the type of damage, hearing loss may be temporary or permanent. Some types of hearing loss can be treated with surgery, medicine, or through the use of a hearing aid; other types are not helped by hearing aids (CDC 2015c).
Possible Reasons for Hearing Impairments
A hearing impairment may be congenital (present at birth) or acquired later due to obstruction, damage, illness, or disease in the outer, middle, or inner part of the ear.
Congenital loss can be caused by
» Infections or other complications during pregnancy (maternal diabetes, rhesus [Rh] factor)
» Premature birth
» Family history of deafness or hearing loss
» Another disability (such as Down syndrome)
Acquired causes of hearing loss include
» Ear infections
» Fluid behind the eardrum
» Head injuries
» Childhood illnesses (measles, mumps, chicken pox)
» Repeated exposure to loud noises (ASHA 2017a)
Impact of Hearing Impairments on Development and Learning
Although many children with hearing impairments do have not additional disabilities, most are eligible for special education under IDEA because the impairment is likely to impact the child’s ability to comprehend verbal language and thus his educational performance. Learning vocabulary, word order, grammar, and other aspects of language is more difficult for children with hearing impairments.
While a hearing impairment does not impact a child’s overall intellectual capacity, it may affect her academically, socially, and emotionally. A young child with even a mild impairment may have difficulty hearing what others are saying, understanding how speech is moderated, learning new words, and saying words correctly. A child’s speech may be difficult for others to understand. If conversation is too frustrating for a child to follow and participate in, she may avoid social interactions with other children, which can lead to the child feeling isolated.
Identifying Hearing Impairments
Although infants typically have a hearing screen early, it’s still important to look for signs that a baby or young child may not be hearing properly. If an infant isn’t startled by loud sounds, doesn’t turn his head when he hears a sound or his name being called, appears to hear some sounds but not others, or doesn’t say single words by the age of 1, he may have a hearing loss (CDC 2015c).
These signs may indicate hearing loss in young children:
» Doesn’t respond consistently to sounds or her own name
» Asks for things to be repeated or often says “huh?”
» Is delayed in developing speech or has unclear speech
» Turns the volume up loud on the TV and other electronic devices
» Doesn’t follow directions (CDC 2015c)
It’s vital to follow up with a physician if hearing loss is suspected. If a child fails a hearing screening, the doctor should refer the child for an evaluation by an audiologist, a professional trained to test hearing. The audiologist uses a variety of tests to determine whether the child has a hearing loss and, if so, what type and to what degree.
Addressing Hearing Impairments
Two important factors to consider in supporting a child’s hearing and language development are hearing technologies and communication approaches.
Hearing Technologies
Children with hearing impairments may benefit from assistive hearing technologies. Assistive devices cannot replace a child’s natural hearing, but they are tools that can help the child hear better and be able to enjoy, respond to, and interact with her environment.
Hearing aids are one of the most commonly used technology devices to help with hearing loss. Young children typically use behind-the-ear (BTE) hearing aids. As a child grows, the device may have to be changed and adjusted. An audiologist can explain what the hearing aid is able and not able to do for a specific child. The audiologist can also program the hearing aid so it can be adjusted for different environments, such as classrooms and outdoor play areas (NIDCD 2017b).
Deaf or deaf
People in the Deaf community differentiate between these two terms:
• deaf identifies the medical condition of being unable to hear
• Deaf identifies the group of people who share the same language—sign—and culture
While many people outside of the Deaf community may not understand this difference, it is important to appreciate that members of the Deaf community do not view deafness as a disability or a condition that needs to be fixed. It is part of their human experience (Padden & Humphries 2006). Members of the Deaf community share a language and culture that is rich in history and traditions across many generations, and Deaf culture needs to be respected in the same ways that other cultures are respected.
Members of the Deaf community take pride in their identity and reject people-first language (e.g., a person who is deaf, a person who is hard of hearing), preferring identity-first language—a Deaf person or a hard-of-hearing person (Lum 2011).
Cochlear implants are a relatively newer option for young children with more profound hearing loss. Instead of amplifying sounds as hearing aids do, a cochlear implant directly stimulates the auditory nerve. It does not cure deafness or restore normal hearing, but it does help an individual understand some speech and sounds in the environment (NIDCD 2017a). If introduced when the child is very young, cochlear implants can make a dramatic difference in hearing.
Frequency-modulated (FM) systems help reduce background noise, improve the clearness of speech, and improve hearing when the speaker is farther away. A microphone is worn on the teacher’s (or other speaker’s) lapel or as a headset or placed on a tabletop. The microphone then transmits radio waves into a receiver that is built into the child’s hearing aid or cochlear implant, worn on the child’s body, or placed in the room.
Communication Approaches
Being able to communicate with others, ask questions, and make their wants and needs known is an essential part of development for all children. A child with impaired hearing might use speech, sign language, or a combination to communicate; some children use augmentative communication devices. There are varying viewpoints on the best approach, and this decision must be made by a family together with their physician and other professionals based on the child and family’s needs and situation.
Speech. Some children with mild or moderate hearing loss learn to use what hearing they have to develop speech. If a hearing impairment is diagnosed early and intervention begins right away, extensive speech therapy or a combination of speech therapy and hearing technologies enables some children to develop speech that is understood by others. Oral language allows children to communicate more easily with hearing individuals.
While some children with mild or moderate hearing loss are able to develop speech, not all do. The ability to hear and discriminate sounds and then reproduce those sounds so that someone else understands them is complex, and many children with more severe hearing impairments are not able to master these skills.
Sign language. A manual communication method, sign language is made up of a system of gestures made with a person’s hands, arms, and body (Stokoe, Casterline, & Croneberg 1965). Sign language is not a single, universal language spoken by Deaf people around the world; each country and region has its own dialect. American Sign Language (ASL) is its own language with its own rules for grammar and syntax. It has almost nothing grammatically in common with spoken English.
Research suggests that all young children who are hearing impaired, even those who have or will receive cochlear implants, benefit from learning sign language as early as possible (Mellon et al. 2015). Pediatricians may advise families to consider the addition of sign language rather than rely solely on using spoken language with their child.
Some students who use sign language will have a sign language interpreter in school with them to help them communicate. This individual is there to interpret for the child, not as a support to the teacher.
Using a combination of methods. Many children communicate using a combination of listening, lip reading, facial expressions, gesturing, signing, and speaking. Known as total communication, the idea is that a child uses whatever methods work best for her.
Some hearing families of young children with hearing loss use a combination of sign language and spoken English known as Manually Coded English (MCE), which uses the same signs of ASL but more closely follows the grammar, word order, and sentence structure of spoken English (Schick 2011).
Augmentative communication devices. Children can also use assistive technology to communicate. Augmentative communication devices, or software on a smartphone or tablet, can be used to generate speech. For example, a child touches a picture or photo to have prerecorded words said aloud. As children get older, this technology can be used in more sophisticated ways; the same kinds of devices have an unlimited vocabulary and can read typed words aloud.
Strategies for the Classroom
When children with hearing impairments are included in general education classes, there is almost always support for the teacher as well as the student. Support may be provided by a teacher of the hearing impaired or a speech-language therapist. This specialist shares information about how the child’s hearing impairment impacts him in the classroom and how to design the environment or activities to encourage independence.
A few simple strategies can help maximize a child’s ability to learn and communicate in the classroom:
» Make sure only one person is talking at a time, since it can be difficult to hear if multiple people are speaking.
» Get the child’s attention before speaking. Keep your face visible (uncovered by hands, hair, or objects) and look directly at the child with a hearing impairment when talking to her.
» Use activities that are hands-on to add a more visual approach to learning. Think beyond using manipulatives in math and science activities; storytelling, for example, can come alive by having the children act it out after you read it.
» Check the acoustics of the classroom to see if there are any ways to improve the listening environment. Adding curtains, rugs, and other sound-absorbing materials is helpful.
» Learn about the child’s hearing devices so you understand how she puts them on and uses them.
» Avoid the temptation to let the child take out his hearing aids sometimes, figuring he can hear well enough without them. To hear as clearly as possible and avoid missing important sounds or verbal directions, the child should wear them at all times.
» As children move into the primary grades, a sign language interpreter may be used in the classroom. Explain to all of the children why this adult is in the room and what his role is. Teach simple signs to everyone. Avoid assuming a child is taking in everything the interpreter is signing, however. Children with hearing impairments may process information differently than hearing children, and other strategies are necessary to make sure they understand what’s being communicated (Livadas 2010).
» While children may not be allowed to carry cell phones in school, in certain situations an older child with a hearing impairment can be allowed to carry a personal cell phone so features such as vibration and text can be used to relay important information.
Hearing Impairments Summary
With appropriate support from their families and professionals, children with hearing impairments can learn to communicate effectively. While a hearing impairment doesn’t mean a child can’t learn, special education is usually necessary to help him learn academically alongside his hearing peers.