Definitions of Hearing Loss and Autism Spectrum Disorder (ASD)
What are the definitions of hearing loss and ASD?
Hearing loss is defined as the total or partial inability to hear sound in one or both ears. Autism Spectrum Disorder (ASD) is a complex neurological disorder. It is characterized by impairments in communication and social interaction, as well as unusual patterns of behaviours, interests and activities. ASD includes Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS) (Effective Educational Practices)
Prevalence of Hearing Loss and ASD
What is the prevalence of ASD?
Research suggests that the incidence rate for ASD is much higher than previously thought. The most current estimates (from studies in Canada and the United Kingdom) indicate that ASD is diagnosed in one out of every 165 children (Ontario Ministry of Education, 2007) The US incidence rate is cited as 1:150. (Syzmanski and Brice, 2008)
ASD is now recognized as the most common neurological disorder (Geneva Centre for Autism, 2006) and has been found throughout the world in families of all racial, ethnic and social backgrounds.
ASD is diagnosed more frequently in males than females. Males are affected four times as often as females. (Ontario Ministry of Education, 2007)
The increase in numbers of children with ASD is thought to be linked to a combination of factors. There is a broader definition of PDD as well as improved recognition of symptoms and changes in diagnostic practices. Diagnosis is now made more frequently and at an earlier age.
What is the prevalence of deafness and ASD?
Research has shown that hearing loss occurs more often in children who have ASD than in children without ASD. (Syzmanski and Brice, 2008)
- 1:150 hearing children have ASD
- 1:76 children with hearing loss have ASD
Causes of Hearing Loss and ASD
Are there some common links between the causes of hearing loss and ASD?
No one knows for sure what causes ASD but there remains much debate. Some syndromes such as cytomegalovirus (CMV) appear to be linked to a dual diagnosis of hearing loss and ASD. There remains much controversy and research continues regarding the causes of ASD!
Characteristics of Hearing Loss and ASD
Characteristics of hearing loss and ASD – are they intertwined?
Although children with hearing loss and ASD present many of the same symptoms as hearing children with ASD, the diagnosis of ASD often occurs later. Both populations present with social communication and language impairments. They show delays and abnormalities in play behaviour as well as restricted activity and interests. (Steinberg, Odyssey, 2008) The following chart identifies the characteristics which may be similar or different.
Deafness and ASD Differential Diagnosis
(This chart may not necessarily apply to ALL students with dual diagnosis because it was taken from an informal sampling. There is limited research surrounding this topic.)
|Characteristics||Severe/Profound Hearing Loss||ASD|
|Orient to Speech||No||No|
|High Levels of Play||Yes||No|
|Data Taken from Provincial School Outreach Program|
Can ASD look like hearing loss?
Several characteristics of ASD may look like those associated with hearing loss. In one study, children with hearing loss were diagnosed with ASD approximately one year later than hearing children. Some studies suggest that the reason behind a delayed diagnosis is the difficulty in distinguishing characteristics of hearing loss from those of ASD. There are limited resources for parents and educators guiding the identification of children with hearing loss and ASD. Late diagnosis may also occur because “…there are relatively few psychological tests that have been made for or even include considerations for children who are deaf. In fact, there are no approved instruments for making a diagnosis of autism in a child who is deaf.” (Szymanski and Brice, 2008, p.13)
For a child with a hearing loss, what are possible ‘red flags’ which may suggest that this child may also have ASD? (as cited by Szymanski and Brice, 2008, p. 12)
- Resists being held
- Doesn’t reply to his or her own name when tapped or when attention is shared
- Has difficulty engaging in shared attention
- Has difficulty imitating facial expressions and actions of caregivers
- Makes limited use of eye contact
- Has difficulty understanding others needs and feelings
- Has unusual reactions to the environment that cannot be attributed to hearing loss
- Lags behind peers in language development
- Has difficulty understanding sign language or verbal language unless it is simplified
- Does not play in the same ways as same age peers (play is rigid and unimaginative)
- Shows an intense interest in a particular activity or object
- Has difficulty interacting with other deaf and hard of hearing students even with language access
- Resists changes in routines, even though changes are clearly communicated
Communication Implications of Hearing Loss and ASD
What are the communication implications of having hearing loss and ASD?
Communication poses the greatest difficulty for children with a hearing loss and ASD. They often have difficulty understanding even the simplest communication from others. One of the most basic communication needs for social interaction is eye contact.
“The lack of eye contact that is common in autism, creates a great barrier for the deaf child in acquiring language, developing social skills, and learning and internalizing appropriate behavioral controls.” (Morton, 2008, p. 5)
“When addressing the needs of any student with autism, one cannot separate communication from his/her behavioural and sensory needs. They are all intertwined.” (J. Casali, Feb. 9, 2011)
What are Visual supports?
“Visual supports are tools that are used to increase the understanding of language, environmental expectations, and to provide structure and support for individuals with autism spectrum disorders (ASD). They facilitate understanding by remaining static or fixed in the individual’s environment. If verbal langue, which is considered transient or fleeting, is the only method used to communicate expectations, provide support and increase an understanding of language, then individuals with ASD may have extreme difficulty.” (University of Illinois, p.1)
What are important considerations when using visual supports?
Visual supports are most effective when:
- Visuals reflect the student’s particular interests or needs
- Students take an active role in using and handling visual materials
- Students establish a connection between the activity or object and the visual
- Visual supports are readily available (kept in consistent location)
- Visuals are durable and replaceable
Although many students with ASD have difficulty with change, transitions and the understanding of auditory input, they tend to have strong rote memories and the ability to understand visual information (from ErinoaKIDS Centre for Treatment and Development – School Support Program, 2009, Structured Teaching)
Hierarchy for Visual Symbols
When using visual symbols, it may be necessary to start with concrete objects and move to more abstract symbols. Where to start on the hierarchy all depends on the child’s ability to recognize these symbols.
Purpose for using schedules:
- To assist a student with understanding a routine. Children with hearing loss and ASD may have difficulty understanding what is or isn’t happening during their day and why changes occur in their routine. They may have difficulty switching from one activity to another and understanding why they cannot do something they want to do at a specific time.
- To assist a student in becoming more independent.
- To teach flexibility
There are many different types of schedules that can be implemented in the classroom. Without schedules, students with ASD may become anxious about what is going to happen and this may translate into challenging behaviours.
- Decide on how the schedule will be broken down
- Create the schedule according to the number of segments in the day (full day, half day, a period, a task, etc.) depending on the capabilities of the student
- Use pictures for the activities that occur in the classroom for a specific student of activity
- Choose the type of schedule you want (individual, whole class)
- Choose the size of the schedule and placement location
- Determine the students understanding of the symbols that will be used. If the student is unable to understand picture symbols then it will be necessary to pair a picture symbol with the real object in the classroom. Labeling items in the classroom will assist in training the student to understand more abstract picture symbols.
- When teaching the student to use the schedule, the student must look at the picture, gather the materials, complete the activity, put the materials away and then refer back to the schedule for the next activity
It is important to limit verbal prompts. If a child needs to be reminded of when to check the schedule then he/she is not using it independently. Building independence is the key! When teaching the use of the schedule, gestures and physical prompts from behind the student are effective, but should be faded as quickly as possible.
Samples and Resources for creating schedules:
First – Then Boards (Thames Valley Children’s Centre – School Support Program, 2008)
- Used to ease anxiety during transitions
- Provides predictability
- Gives the student information about what will happen, but doesn’t overwhelm the student
- Reinforces completion of tasks that are not desirable
- Breaks larger schedules down
- Can motivate students since they are able to see that a more desirable task follows the less desirable one (i.e. first writing, then computer)
- Create a simple two-part communication board.
- Represent the activity on a card using words, pictures or drawings. Place the card in the “first” section.
- Place the second activity in the “then” section.
- Once the first activity is completed, remove this picture and move the “then” activity to the “first” section
- Add a new picture in the “then” section for the next event that will happen.
Samples and Resources for making visual instructions:
Mini-Schedules em>(Centre for Autism and Related Disabilities – University of Florida, retrieved 2010)
Purpose for using mini-schedules:
- A mini-schedule breaks a larger task down into smaller steps which are easier for a child to handle.
- It is useful for certain events or tasks in the daily schedule where a child has difficulty.
- It insures that everyone follows the same sequence of events if different people assist the child with the task.
Mini-schedules can be used for: going to the bathroom, morning routines, getting ready for school, getting ready to eat, preparing for an activity etc.
(Thames Valley Children’s Centre – School Support Program, 2008)
(Centre for Autism and Related Disabilities – University of Florida, retrieved 2010)
Purpose of a calendar:
- A calendar is a good way to help a child understand what is happening over the course of a week or month.
- It presents information in a visual form that students can understand.
- It can decrease anxiety about upcoming events and changes.
- A calendar can tell a child which days are school days and which days are not. It can also inform a child when an unusual event will take place such as going to the doctor, etc.
- Unusual events which interrupt the regular routine can confuse children, resulting in behavior problems.
- oBecause the information is there on the calendar the child can refer back to it as often as they need to. If and when there are changes, it is important for the child to take part in changing the calendar. The calendar should be kept as simple as possible and only put what is important to the child on the calendar.
Procedure for creating a calendar:
- Label and number the monthly calendar
- Use the pictures provided in the samples section or create your own symbols for events
- Place the symbols on the appropriate dates (do this with the student)
- When an event is cancelled, cross out or use the “No” symbol to show that this event will not occur
Samples and Resources for creating a calendar:
The “No” symbol can be used with both choice boards and picture schedules. “No” on a choice board can indicate that a toy (for example) is not available. “No” on a picture schedule can show that an event has been cancelled.
(Thames Valley Children’s Centre – School Support Program, 2008)
- To increase independence within an activity or lesson
- To provide instructions in a concrete manner
- Select pictures or words that are appropriate to depict each step of the activity.
- Introduce one picture and support the student in completing the instruction.
- Increase the number of steps in the instruction only when the student is independent in completing the first step.
Samples and Resources for creating a calendar:
What is PECS ?
- PECS stands for the Picture Exchange Communication System
- This system allows children with communication deficits to initiate communication with others.
- PECS requires the child to exchange a picture card with their communicaton partner, therefore generating a social interaction.
*A teacher/professional must be trained and certified to initiate and use the Picture Exchange Communication System!
Why use manual signs?
- Estimates are fairly consistent that 50% of children with autism are nonvocal (American Sign Language vs. PECS )
- The use of manual signs accelerates the acquisition of speech by stimulating areas of the brain that are associated with speech and language
- Manual signs can provide an augmentative means of communication
- The use of manual signs can reduce frustration by providing a way to expressively communicate in situations where verbal communication may not be successful.
The National Academy of Science in its report, Educating Children with Autism as referenced in American Sign Language vs. Picture Exchange Communication System, states, “There is no evidence to suggest that sign language interferes with the development of speech. There is evidence that sign language enhances the use of speech for some children.” (p.3)
Using a variety of strategies is the best way to enhance the acquisition of language and communication skills. Sign language, gestures, speech, facial expressions, body language, mime, pictures, PECS, written words, and fingerspelling are all effective tools for developing communication and language skills. (Bradley, Krakowski and Thiessen , 2008)
Structured Teaching Environment
What aspects make up a structured teaching environment ?
Students with hearing loss and ASD can display impairments in social interaction, impairments in communication, and repetitive and stereotypic behaviours, interests and activities. Each student has unique needs which must be considered. Individualizing their program and structuring the learning environment is key to their success.
Such an environment
- reduces anxiety
- promotes independence
- provides clear expectations
- identifies functional areas of the classroom
- indicates location of materials
- reduces distractions
There are 4 aspects of a structured teaching environment – Physical Structure, Visual Schedule, Work System, and Visual Structure.
from ErinoaKIDS Centre for Treatment and Development – School Support Program, 2009, Structured Teaching
Physical structure refers to the way the environment is organized in order to establish an interesting, clear and manageable space for the students.
When implementing physical structure of the classroom, some areas to consider may be:
- Independent work area (no staff involvement)
- Life skills / self-help
- Quiet area
- Whole class teaching
- Play / leisure
- Vocational skills
Areas of the classroom should be:
- Meaningful to the student by dividing spaces into distinct functional areas that are labeled with visual clues, using colour and moveable structures to create boundaries. Some students may need a work station that is closed off to other students, while some students may be able to work in more open areas.
- Interesting to the student by considering his/her strengths and interests
- Visually supportive to ensure rules and expectations are understood. Each work station should indicate the expectations – what needs to be done, how much needs to be done, when the student will be finished the task, and what’s next.
- Clearly defined by where and how the furniture is placed. Taping outlines on the floor to define the various areas, and chairs labeled with students’ names may also be beneficial.
Things to consider:
- Traffic patterns
- Auditory and visual distractions — Many students with autism are sensitive to auditory input and have difficulty processing auditory information. Work areas should be placed away from areas where there is a lot of noise and movement.
- Seating arrangements
- >Use of visual supports
- Accessibility to instructional material
- Age of student
- Student’s learning style/needs
Examples of Physical Structure
(from ErinoaKIDS Centre for Treatment and Development – School Support Program, 2009, Structured Teaching)
Schedules provide a meaningful sequence of activities. Schedules may help the student answer the questions:
- What activities will occur?
- When will the activities occur?
- Where will the activities occur?
Schedules may be used to:
- Improve comprehension
- Improve the ability to understand routines
- Improve the ability to transition
- Reduce challenging behaviours and anxiety
- Promote independence (decrease of adult prompting)
- Increase flexibility
- Provide structure
- Organize daily activities in a predictable manner
- Be useful to redirect the student to specific activities
Schedules are strategies used to clarify expectations and increase the student’s understanding around what will be occurring throughout the day. Schedules can be used with the entire class, with a group or with individual students.
Things to consider when implementing and individualizing schedules:
- What is the goal of the schedule?
- Identify the activities / subjects for the student
- How are you going to teach the schedule?
- Where is the schedule going to be placed in the room?
- Is the strategy at the student’s developmental level?
Individualize the schedule by considering:
- Visual recognition stage – Objects, pictures / photos, icons, text or combinatio
- Length – 1 activity at a time, 2 -3 activities, half day sequence or full day sequence
- Orientation – Top to bottom, left to right or right to left
- Location – On / in desk, in transition area(s), portable, locker or other
- Manipulation – Carry, match, use or point to objects /pictures / text from schedule
- Indicating finished – ‘All done’ pocket /container, move pictures / words to various locations, check off, highlight or cross off completed activities
Samples and Resources for Visual Schedules:
Work systems provide a systematic way to approach the tasks that need to be completed. They assist the student to answer the questions:
- What work am I supposed to do?
- How many tasks are there to do?
- How am I progressing and when am I finished?
- What happens after the task is finished?
Work systems are strategies that provide familiarity and predictability for students when they are approaching their work. They are tools for sequencing, independence and generalization of skills. They may reduce the time the student requires adult assistance and direct supervision. Work systems assist in clarifying the concept “finished” in a concrete and meaningful way for individual students.
Ways to individualize work systems:
- Based on the student’s level of understanding (e.g. Text, pictures, numbers, colours or objects)
- Types of work systems (e.g. left to right, top to bottom, matching or text)
- Length (e.g. 1 task assigned, 2 -3 tasks assigned, or Time allotted is ______)
(e.g. Put items into a ‘finished’ location, put things away, or mark off list)
- How much movement is involved during the session (e.g. Stay seated throughout, move within a small work area, or move within a larger area)
Things to consider when developing work systems:
- Interspersing preferred and non-preferred activities
- Providing a preferred activity as the last task
- Using a visual support to cue the student back to the schedule
Things to consider when developing work systems:
- When creating a task, ensure that there is a clear goal for the student
- The same task can achieve different goals. For example, completing a puzzle can look different
- if the goal is independence (student completes the task on their own)
- if the goal is to increase social skills (play with another student)
- or increase communicative intent (to ask for the puzzle)
Amplification: (hearing aids and Soundfield/FM systems)
Accommodations for hearing loss:
- Ensure ongoing audiological assessment
- Be aware of the type and degree of hearing loss
- Use amplification as recommended by the audiologist. Do a daily listening test to ensure that all equipment is working effectively. (Be aware that some students may be overly sensitive to sound or tactile defensive with this equipment)
Keep in Mind
Clear expectations and consistency are essential. All staff working with the students need to be knowledgeable and aware of individual student’s needs. Consistency should be embedded throughout the program
Most students with ASD require direct instruction in social skills. Activities can be designed to teach about emotions in self and others and how to respond in certain situations. Social stories are very useful for this purpose. (A social story is a short story written about a specific social situation, how others might respond in the situation and how the student should respond.)
A functional curriculum should be considered for some students. Daily living skills, community skills, recreation, leisure and employment are aspects of a functional curriculum. The goal should be to foster independence.
Most students with hearing loss and ASD may benefit from the use of visual means to develop literacy skills.
Most students with ASD have sensory needs. These students may seek or avoid various types of sensory input. An occupational therapist or professional trained in sensory integration should be involved to provide suggestions for sensory stimulation throughout the day.
What we know about children with hearing loss and have ASD is limited. Some of the information may be controversial and other information is still being investigated. “Consequently, deaf children who have autism need an educational program that (1) identifies concerns early and (2) considers both the deafness and the autism so that appropriate interventions can be designed.” (Steinburg, 2008, p8)
Education should include specialized instruction and related services. Both are necessary for the student to learn and develop.m Therefore, ongoing in-school intervention sessions (ie. Speech-language, communication, and occupational therapy, audiologic services) are also part of the school day and should be provided by professionals who understand both deafness and autism. (Steinburg, 2008)
The most important thing to remember when working with students with hearing loss and ASD is that “one size does not fit all”. Each child has different strengths and needs and they need to be recognized in order to assist the child in reaching his/her fullest potential.
References and Resources
American Sign Language vs. Picture Exchange Communication System in the Development of Verbal Language in Children with Autism: A review. Retrieved October 27, 2010 from http://www.behavior-consultant.com/asl-pecs.htm
Beals, K. (2004). Early Intervention in Deafness and Autism – One family’s experiences, reflections, and recommendations. Infants and Young Children, 17(4), 284-290.
Bradley, L., Krakowski, B., Thiessen, A. (2008) It’s a matter of learning what works in teaching student with deafness and autism. Odyssey, 9(1), 16-18.
Carr, E.G. et al. (1978) Acquisition of Sign Language by Autistic Children 1: Expressive Labeling [Electronic version]. Journal of Applied Behavior Analysis, 11, 489-501.
Centre for Autism and Related Disabilities – University of Florida CARD UF Visual Supports. (CARD UF) Visual Supports. Retrieved October 27, 2010 from http://card.ufl.edu/content/supports.html
Chase, M. Communication Skills – The importance of eye contact. Retrieved November 1, 2010, from . http://www.helium.com/items/663607-communication-skills-the-importance-of-eye-contact
Communication Boards. Retrieved November 1, 2010, from http://www.speechdisorder.co.uk/communication-boards.html
ErinoaKIDS Centre for Treatment and Development – School Support Program Structured Teaching. (2009) Mississauga, Ontario.
Effective Strategies for teaching children with autism spectrum disorders. (2007) Retrieved October 27, 2010 from http://www.autism-world.com/index.php/2007/03/25
Hutson, S. (2008) Using Sign Language with an Autistic Child. Retrieved November 1, 2010 from Buzzle.com
Illinois State University. Visual Supports Fact Sheet. Retrieved February 9, 2011, from www.illinoisautismproject.org/iattap_Visual_Supports_Fact_Sheet_1_.pdf
Jordan, Rita. Signing and autistic children [Electronic Version]. Communication, 19 (3), 9-12.
Lawrence, J. (1999) How to Use Visual Supports to Help People with Autism. Retrieved October 27, 2010 from http://www.angelfire.com
Morton, D. (2008). Deafness and Autism. Odyssey, 9(1), 4-5
Ontario Ministry of Education. (2007). Effective Educational Practice for Students with Autism Spectrum Disorders –A resource guide. Toronto, ON: Ministry of Education
Phillips, M. (2002) Sign Language and the Brain. Retrieved November 1, 2010, from http://faculty.washington.edu/chudler/sign.html
Plumley, K. (2009) Sign Language and Autism – Teaching Speech and Communication to Autistic Children. Retrieved October 27, 2010 from http:///www.suite101.com/content/
Sign language and Autism (Babies and Sign Language) Retrieved November 1, 2010 from http://www.babies-and-sign-language.com/autism.html
Steinberg, A. (2008) Understanding the need for language. An introduction to the Odyssey special issue on autism and deafness. Odyssey, 9(1), 6-9.
Szymanski. C, Brice, P. (2008). When autism and deafness coexist in children – what we know. Odyssey, 9(1), 10-15.
Thames Valley Children’s Centre – School Support Program – ASD. Visual Strategies Kit (second edition). 2008. London, ON
University of Michigan. Alternative Augmentative Communication for Children with Autism: PECS and Sign. Retrieved October 27m 2010 from http://sitemaker.umich.edu/356.kobza/sign_language
Walker, J.G. (2009) Sign Language and Autism / Special needs. Retrieved October 24, 2010 from Your talking Baby
Yack, E., Sutton, S, Aquilla, P. (1998). Building Bridges through Sensory Integration. Weston, ON: Print 3.
Jan Casali, M.A., REG’D CASLPO, Speech and Language Pathologist, Resource Services – Outreach Programs, Ministry of Education, Provincial Schools Branch
Susan Kennedy, Resource Consultant – Resource Services Outreach Programs, Ministry of Education, Provincial Schools Branch
Sue Wiffen, Autism Program Support Specialist for the AMDSB