Deafness and Hearing Impairments

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According to the World Health Organization, disabling hearing loss will affect nearly 2.5 billion people by 2050. Disabling hearing loss is a hearing loss greater than 35 decibels. The World Health Organization reports that nearly 80% of people with disabling hearing loss live in low- and middle-income countries. National estimates of infants born with hearing loss are between 1 to 6 infants per 1,000 births (mnlowincidenceprojects.org, n.d.).

Normal hearing has a threshold of 20 decibels or better in both ears. Anyone not able to hear as well is considered to have hearing loss, which can affect one or both ears and may be categorized as mild, moderate, or profound. People who are considered hard of hearing may still be able to communicate vocally but may have difficulty speaking, depending on the level of hearing loss. They may utilize hearing aids, cochlear implants, or other assistive devices. People with profound hearing loss have little to no hearing and are prevented from understanding speech through their ears. They may use sign language or assistive devices for communication.

Video: Hearing Loss Treatment is Life-changing (2:42)

Causes

There are two types of hearing loss. Conductive hearing loss is linked to problems with the ear canal, ear drum, or middle ear and its bones (the malleus, incus, and stapes). Sensorineural hearing loss is known as nerve-related hearing loss. Causes of hearing loss can occur at various stages of life. During the prenatal period, genetic factors and intrauterine infections can affect hearing. During birth, a newborn may experience a lack of oxygen, severe jaundice, and low birth weight, among other perinatal experiences that can cause hearing loss. Children during early childhood and adolescence may experience chronic ear infections, meningitis, or other afflictions that affect hearing. Adults may also encounter chronic diseases, sensorineural degeneration, trauma to the ear or head, loud noises or sounds, viral infections, and/or progressive genetic hearing loss (World Health Organization, n.d.).

The Hearing Loss Association of America lists other causes of conductive hearing loss to include allergies, perforated eardrum, tumors, impacted earwax, or foreign objects in the ear. Sensorineural hearing loss occurs from exposure to loud noise, aging, head trauma, virus or disease, autoimmune inner ear disease, heredity, otosclerosis, and tumors. Noted is the loss of hearing from exposure to loud noise. This type of hearing loss is preventable but not reversible.

Treatment of Hearing Loss

Options for hearing loss treatment are numerous but depend on the cause of the hearing loss, the degree of loss, and the age of the person with the loss. Treatments for conductive hearing loss include the option to have corrective surgery. This option is available for some birth defects that affect hearing, some damage to the ear from head trauma, and otosclerosis (an abnormal bone growth within the middle ear that causes progressive hearing loss). Amplification through hearing aids or a surgically implanted device depends on the hearing nerve’s condition. Antibiotics or antifungal medicines to treat ear infections or chronic middle fluid are also a form of treatment. If a tumor is present, surgical removal is usually required.

Sensorineural hearing loss treatments vary according to the cause of the loss. Hearing loss due to a virus may be medically treated with a corticosteroid. Hearing loss from head trauma or changes in air pressure, such as in airplane travel, may need emergency surgery.

Assistive technology can be helpful to someone deaf/hard of hearing. Hearing aids are the most common tool. It is important to note that hearing aids amplify all sounds in the room or environment. A hearing person can filter out background sounds better than someone with hearing aids. Meniere’s disease is a sensorineural hearing loss that can be treated medically with a change in diet, diuretics, and medications. Symptoms include hearing loss, tinnitus (ringing in the ears), and vertigo (dizziness). People with irreversible sensorineural hearing loss (the most common cause) may use hearing aids. This type of hearing loss can also be surgically treated with cochlear implants.

Cochlear Implants

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A cochlear implant is a small, complex electronic device that can help provide a sense of sound to a person who is profoundly deaf or severely hard of hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin. National Institute on Deafness and Other Communication Disorders: Cochlear Implants

For more than a generation now, cochlear implants have, for some, been transforming the experience of deafness. In this video, “Between Sound and Silence,” director Irene Taylor Brodsky delves into conversation with a cohort of people living that transformation. As the child of deaf parents and the mother of a deaf son, Brodsky delves into a complex realm where deafness and hearing (rather than absolute states) are territories of human experience to be bridged and explored. Between Sound & Silence: How Technology is Changing Deafness

Communication and Cognitive Development

The medical approach views the disability as a bodily impairment that needs to be fixed and overcome to be comparable to a hearing person. The integrative-social approach considers deafness to be one of the child’s characteristics, and the Deaf community as a group sees deafness with unique needs, such as sign language, which is of equal importance. Nevertheless, selecting a communication style that is tailored to the child’s needs is crucial for their development (Avraahami-Winaver et al., 2020).

Interestingly, more than 90% of parents of deaf/hard-of-hearing children are hearing (Mitchell & Karchmer, 2004, as cited in Eichengreen & Zaidman-Zait, 2020). Most deaf/hard-of-hearing children have limited opportunities for daily interactions with other deaf/hard-of-hearing children or adults, which puts them at risk for loneliness and social difficulties (Eichengreen & Zaidman-Zait, 2020). The deaf/hard-of-hearing child may not be able to communicate and discuss ideas, feelings, or worldly topics of reality and fantasy during critical stages of development (Avrahami-Winaver et al., 2020). The result is disconnectedness and emotional distance with parents, difficulty with their own identity as a person who is deaf/hard of hearing, and a lack of exposure to the Deaf community (Young, 2018, as cited in Avraahami-Winaver et al., 2020).

The effects of hearing loss on cognitive development include speech and language development. The ability to communicate with peers is essential to forming relationships (Fitzpatrick et al., 2020). Relationships and friendships reinforce personal identity and are important for the well-being of people and their communities (Cagulada & Koller, 2020). A child with hearing loss can be negatively affected in their development of oral speech and speech intelligibility (Fitzpatrick et al., 2020). Lower morphological awareness and receptive language skills are present in those children who are deaf/hard of hearing, which can be improved with the use of hearing aids and cochlear implants provided at an early age. Technological assistance (i.e., hearing aids, cochlear implants) can be combined with speech therapy and high-quality conversation.  Social situational conversations and pragmatic skills are typically below developmental age levels when compared to typical hearing peers (Fitzpatrick et al., 2020).

Previous research studies have shown that deaf/hard-of-hearing children request clarification during conversations less than their typical developing peers, even though they are missing some of the conversation. Children who are deaf/hard of hearing are often ostracized and excluded from their peers’ conversations and social interactions (Cagulada & Koller, 2020). However, Fitzpatrick et al. (2020) found that deaf/hard-of-hearing children have pragmatic strengths rather than weaknesses in conversations with adult researchers. Cagulada and Koller (2020) interviewed parents of deaf/hard-of-hearing children. The parents noted a lack of understanding by teachers, peers, and society, which could adversely influence children’s social relationships. One concern pointed out was the need to giving enough time to respond to questions. If the child did not respond to their peers quickly enough, the peers would just walk away (Cagulada & Koller, 2020). Experiences of exclusion and victimization by peers have also been found in cross-cultural studies (Cagulada & Koller, 2020).

Deaf and hard-of-hearing people have their own preferences for communication when they are not face to face. Some may communicate through email or text. They may prefer to interact through social media. Others may use a “relay interpreter” or “communication assistant.”

Do not be afraid to speak to someone who is deaf or hard of hearing. To get the attention of a person with hearing loss or deafness, touch the person lightly, wave your hand, or use some other physical signal. When speaking, stay within one to three feet of the person who is deaf/hard of hearing. If you are not within that range, they may not hear everything you say (Cagulada & Koller, 2020). If the person is using a sign language interpreter, speak to the person who is deaf rather than the interpreter. If the person is lip-reading, speak directly to them, keeping your speech slow and clear, but do not exaggerate your mouth movements, and never shout. Facial expressions, gestures, and body movements are useful for the deaf/hard-of-hearing person to understand what you are saying.

Video: Kids Meet a Deaf Person (7:47)

American Sign Language

Video: Sign Language is my Super Power (8:55)

How do we convey the beauty of sign language to the world at large? Austin Vaday welcomes us into the rich culture of American sign language and shares his efforts to bridge the gap between the hearing and Deaf communities. Austin Vaday is a 21-year-old software engineer, innovator, and entrepreneur. Since becoming deaf at the age of three, Austin has proved to the world that disabilities are superpowers, and not disadvantages. At only 17 years old, Austin experienced his first of four software engineering internships at NASA and Amazon. When he was 19 years old, Austin co-founded a startup, Aquaint, a tool for social media discovery and organization. Currently a computer science student at UCLA, his technical skillset includes web, iOS, and backend development. In May 2017, Austin started Signs For Humanity, a social media initiative that seeks to spread the beauty of sign language with all of humanity. In just six short months, his educational videos have generated over 3.5 million views and have been watched from all around the world. Some say that Austin’s true talent is not in his technical ability but in his ability to inspire and motivate others. This talk was given at a TEDx event using the TED conference format but independently organized by a local community.

Diverse Learners: Individual Differences

Diverse learning needs among deaf/hard-of-hearing students depend on several factors; how old they were when they lost their hearing, whether their parents are deaf/hard of hearing, and whether they have any family members who are deaf/hard of hearing.

Children who are deaf/hard of hearing tend to select hobbies and activities where language, communication, and socializing are not key to success (Cagulada & Koller, 2020). Parents often comment that their children enjoy physical activities (such as tag) in which the child does not have to speak but can instead be free to participate and enjoy the activity (Cagulada & Koller, 2020).

The U.S. Department of Health and Human Services provides the following list of auxiliary aids and services:

• Qualified interpreters*
• Note takers
• Transcription services
• Written materials
• Telephone handset amplifiers
• Assistive listening devices
• Assistive listening systems
• Telephones compatible with hearing aids, closed-caption decoders, open and closed captioning
• Text telephones (TTYs)
• Videotext displays or other effective methods of making aurally delivered** materials available to individuals who are deaf or hard of hearing

* A qualified interpreter refers to an interpreter who is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary.

** Aurally delivered information means information that is delivered through sound, including speech, intercom, telephone, recorded message, loudspeaker, and alarm, among others.

Factors to keep in mind in the classroom include the following:

• What services does the child need?
• Does the child have hearing aids? Do you have extra batteries available?
• Does the child need an FM system that amplifies the teacher’s voice? Are there extra batteries available for that system?
• Does the child use sign language? Do you have a sign language interpreter in your school?
• Are the other students in class aware of one another’s individual needs?
• As a teacher, are you prepared to teach someone who is deaf/hard of hearing?

To avoid stigmatization or exclusion of the child who is deaf/hard of hearing, invite the child to share their perspectives on what they need from their peers, i.e., standing one to three feet away, looking at them when speaking, and so on. As the teacher, make sure that batteries are fresh, and always keep spare batteries in the classroom. A parent in Cagulada and Koller (2020) research stated the following:

“In a classroom setting, just because she’s looking at you, and her batteries are dead and the FM system is broken, doesn’t mean she can hear you.”

If the child requires hearing aids or an amplification system, you, as the classroom teacher, need to ensure that they are working. An unacceptable response from a teacher or leader in a lecture would be as follows: “My teacher voice is loud enough; I do not need a microphone.” This is not true for the deaf/hard-of-hearing person. Always defer to the needs of the students in your classroom. Also, utilize closed captioning for any videos you are using in class. The words on the screen not only help the deaf/hard-of-hearing student but may also help other students in the room. Any audiobooks should be available in a paper copy as well.

Self-determination and Motivation

Self-determination and motivation accompany each other. Luckner and Sebald (2013) define self-determination as “a combination of attitudes, knowledge, and skills that enables individuals to make choices and engage in goal-directed, self-regulated behavior” (p. 1).  A foundation of self-determination is one component of a successful transition to life beyond high school. Self-determination contains the following elements; self-awareness, decision-making, goal-setting, problem-solving, self-regulation, and self-advocacy (Luckner & Sebald, 2013). Self-determination can be taught, but opportunities must exist for development/promotion; with these opportunities, one can practice self-determination skills  (Lucknew & Sebald, 2013).

Motivation, particularly intrinsic motivation, relies on the fact that people tend to possess self-determination. People also prefer to participate in activities of their own choosing rather than ones that are attached to extrinsic rewards or required to complete (Luckner & Sebald, 2013).

Promoting self-determination for children who are deaf/hard of hearing can be offered through activities such as providing opportunities to choose activities, identifying their interests, role-playing situations to practice self-advocacy skills, and increasing students’ understanding of their legal rights under the Individuals with Disabilities Education Act (IDEA) and the Americans with Disabilities Act (ADA). Families of children who are deaf/hard of hearing play a role in the development and support of self-determination for their child. Assisting children with decision-making promotes their growth of self-determination and increases their motivation. However, teachers and families must be careful to foster the child’s independence in making choices. An understanding of the families’ diversity must be honored. Teachers should engage in discussions with families about their views of self-determination to ensure that the goals for the child and the values of the family are respected and included (Luckner & Sebald, 2013).

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Learning, Assessment, and Accommodations in the Classroom

Children who use sign language in the classroom do not necessarily claim English as their primary language. They may struggle with printed English (Kelly & Bara-Cikoja, 2007, as cited in Smith & Allman, 2018). Researchers have found evidence that children who are bilingual and deaf use signs at the same time they are processing the written words of a language, whether it be English or any other language.

In a study involving the assessment of grammatical structures, deaf/hard-of-hearing students performed significantly worse than a hearing group of students on both the vocabulary pretest and main test  (Smith & Allman, 2018). Recommendations for the successful assessment of diverse deaf/hard-of-hearing students include the following:

• Widely accepted accommodations for administering and scoring protocols
• Reporting results that look at the student through a global lens
• Aligning technology with both instruction and assessment

If a student’s hearing loss interferes with the development of nonverbal and nonauditory reasoning, investigators must move beyond evaluating listening and spoken language abilities and investigate a variety of neuropsychological measures for such students (Conway et al., 2011, as cited in Smith & Allman, 2018).

When considering accommodations for students who are deaf/hard of hearing, consider how accessible the language of the content is based on the students’ needs. Accessibility for accommodations and modifications requires an understanding of the individual students’ linguistic ability. Students’ needs must be aligned with the intended measurement, whether it be a formal or informal assessment. If the student receives instruction using American Sign Language or other visual communication, without access to printed content, testing content knowledge using printed material may impede students who are deaf/hard of hearing in terms of fully indicating what they know (Qi & Mitchell, 2012, as cited in Smith & Allman, 2018). The Individualized Education Plan (IEP) team must clarify the testing requirements and align them with the teaching approach utilized by the classroom teacher. Classroom exposure to technology for deaf/hard-of-hearing students is not a guarantee of success. Integrating technology use in lessons, including hypertext and web page language, along with encouragement may motivate students to explore the content further (Smith & Allman, 2018).

The National Association of State Directors of Special Education (2018) uses the following process for IEP teams to select and implement assessment accommodations for students who are deaf/hard of hearing:

1. Expect successful student participation in grade‐level content standards and assessments.
2. Become acclimated to available accommodations and resources available for instruction and assessment.
3. Provide necessary individualized accommodations and resources for both instruction and assessment.
4. Provide equivalent access to accommodation and resources during both instruction and assessment.
5. Re‐evaluate regularly current accommodations and the need for any new ones for instruction and assessment.

Specific considerations for assessing students who are deaf/hard of hearing include the following:

• Diversity of the student
• Cognitive differences of the student
• Language of instruction
• Cultural lens of the student
• Language learning experiences of the student

Interpreting the assessment data must be done with caution. The results have an intense impact on IEP team decisions. A technology-based approach may help ensure an equitable assessment of students who are deaf/hard of hearing (Smith & Allman, 2018).

Access to classroom content is dependent on the acquisition of language, speech production, literacy and math knowledge, and social skills developed before beginning school. Students who are deaf/hard of hearing may be behind their peers (Dettman et al., 2022). The impact of hearing loss on these developmental stages may be impacted, depending on the onset of the hearing loss, degree and type of hearing loss, and when the age intervention began (Dettman et al., 2022).

Teachers and paraprofessionals indicate they play diverse roles when working with a deaf/hard-of-hearing student in their classroom. They are advocates, communicators, interpreters, technical assistants, social workers, disciplinarians, and teachers (Dettman et al., 2022). These teachers and paraprofessionals share that they spend most of their time on the following areas when working with deaf/hard-of-hearing students: pre-teaching concepts, clarifying classroom themes, reviewing homework, testing protocols, and assisting with technological problems.

Language Development

Pre-school and primary school deaf/hard-of-hearing children’s language competency is affected by limited access to language stimulation, either via sign language or oral language. Researchers recommend accessible and intensive language enrichment programs (Hettiarachchi et al., 2021).

Researchers in the field (Heathfield, 2011, as cited in Kirsch, 2016) recommend incorporating a range of strategies to enable language comprehension such as:

• Actions
• Gestures and mime
• Repetition of key phrases
• Tone of voice
• Use of props
• Interactive audience participation
• Character empathy and expression

One research study conducted by Hettiarachichi et al. (2021) utilized the use of story boxes with children who were deaf/hard of hearing to increase expressive and receptive vocabulary.  These story boxes included a story script, a simple song, multi-sensory objects, and key signs for the targeted words. Prompts were given to students just prior to a targeted word being used. Teachers incorporated oral language as well as sign language during the activity. Researchers noted the necessity to have the deaf/hard-of-hearing students’ attention prior to the prompt. Results revealed growth in both expressive and receptive vocabulary for the targeted words.

Online Instruction

The online classroom can provide greater accessibility for the deaf/hard-of-hearing student. Face-to-face classes utilizing interpreters include delays that occur between the hearing professor and the ASL interpreter. Deaf/hard-of-hearing students may also feel isolated from and/or left out by their hearing peers due to feeling that they are not being properly communicated with in class (Counselman Carpenter et al., 2020 ). However, the online classroom provides many opportunities for deaf/hard-of-hearing students to interact, learn, and understand, which may not have been present in traditional in-class instruction due to the option of having a live captioner. Another strength is that online courses deliver print material in a different format, increasing accessibility to those who experience print-based impairments. Instructors may post video/media clips without appropriate captioning. Instructors often rely on software with which they are familiar simply due to its familiarity when beginning to teach in an online setting, or they may use such software because the administration decides to purchase the newest model. However, it is important to think about whether the software is comparable with adaptive software for students who are visually impaired or deaf/hard of hearing.

Five tips for teaching practice include: 1) mindful preparation without assumptions, 2) using and advocating for institutional support, 3) building a working relationship with the student, 4) creating an inclusive classroom environment, and 5) minimizing the burden on the student (Counselman Carpenter et al., 2020). Begin by ensuring that all videos used in online teaching are closed captioned. Also, check the captioning for accuracy before sharing. Communication between the instructor and student is essential to a successful course. Carpenter et al. (2020) recommend having a discussion with the deaf/hard-of-hearing student before or after each class to check in with them. Discuss the use of a sign language interpreter, closed captioning, amplification needs, and any other things that the student needs you to know. Also, be aware of any background or interference sounds.

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Other Factors Affecting Learning (e.g., culture, environment, alcohol, tobacco, drugs, technology, families)

Distractions from outside noise or a noisy classroom environment negatively affect the listening experiences of children, whether deaf/hard of hearing or not.  These noisy environments put children at risk for potential deficiencies in speech perception, language acquisition, and educational outcomes (Nelson et al., 2020).  The impact can be severe for children who are deaf/hard of hearing, as such distractions create barriers to learning. Classroom sounds that must be considered include:

• the sounds of other children talking or whispering, and adults having side conversations
• chairs sliding on floors, students shuffling papers, or rummaging through backpacks
• noises from heating, ventilation, and air conditioning
• fans, electronics, buzzing from fluorescent lights
• hallway or outside noises

Purposefully reducing the noise that impacts classroom listening can result in lower student stress, improved behavior, and a positive impact on students’ educational experiences (Nelson et al., 2020). The ASHA (2004) National Standard on Classroom Acoustics and the American National Standards Institute (2010) recommended that the noise level in unoccupied classrooms not exceed 35 dB(A), and the signal-to-noise ratio (SNR) in the classroom should be at least +15 dB (ASHA, 2004). Thus, the teacher’s voice should be at least 15 dB louder than the noise level of the classroom.

Researchers have reported that comprehending language in noisy environments increases the listener’s cognitive burden when continuous attention and concentration are required (Nelson et al., 2020).  Children who are deaf/hard of hearing require more effort to listen and pay attention. As a result, they may have more difficulty with speech perception and may experience more fatigue when in noisy environments in comparison to their hearing classmates (Nelson et al., 2020).

Teachers should also consider their personal teaching style. In a lecture situation where the teacher walks around the room while speaking, a student who is deaf/hard of hearing will not be able to see facial expressions or read lips. This is also true if the teacher continues to talk while writing on a board with their back to the students (Nelson et al., 2020). A common accommodation for students is to seat them in the front of the classroom. This seating arrangement will help them hear or see the teacher or anyone in the front of the room. However, they will not be able to hear their classmates sitting behind them during instruction. Consider instead placing the student more toward the middle of the classroom toward one side or the other so that the deaf/hard-of-hearing student can see the teacher’s as well as the other students’ visual or facial cues.

Student learning and achievement are goals of educational systems. Another priority is for students to be successful in social situations with their peers, which also lays foundations for future academic, vocational, and personal successes. Students being able to hear direct and incidental conversations in the hallways, before and after school, during lunchtime and recess, and during other social exchanges can contribute to developing successful peer relationships (Nelson et al., 2020). Other social and academic situations that play an important role in the student experience include fully participating in large-group activities, hearing announcements that come over the speaker system into the classroom, and following the dialogue at a student assembly (Nelson et al., 2020). The teacher and parents must consider these needs and discuss accommodations and possible self-advocacy skills for the student.

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Deeper Dive

Book

Optimizing Outcomes for Students who are Deaf or Hard of Hearing

In this book, the authors emphasize the diversity of the deaf and hard-of-hearing student population, the range of services and supports that must be available, and the idea that “one size does not fit all.” The authors believe that this illustration can capture many of the points they make in a simple and colorful way. While everyone brings their own interpretation to any work of art, in this picture, the authors see spoken language represented by listening technology, visual communication (such as American Sign Language), and the important role of trained professionals represented by the attentive and involved teacher.

Web Resources

Kindergarten Readiness in Children Who are Deaf/Hard-of-hearing Served in Early Intervention 

Minnesota Low Incidence Projects

World Health Organization Facts Sheets: Deafness and Hearing Loss 

Inclusion Toolkits: Deaf Hard of Hearing

MN Department of Human Services: Dead Hard of Hearing

Effective Communication for those who are Deaf or Hard of Hearing

Hearing Loss: Types, Causes, and Treatment

References

Avrahami-Winaver, A., Regev, D., & Reiter, S. (2020). Pictorial phenomena depicting the family climate of deaf/hard of hearing children and their hearing families. Frontiers in Psychology, 11(2221). doi:10.3389/fpsyg.2020.02221

Cagulada, E. & Koller, D. (2020). “It’s a hearing world”: Parents’ perspectives of the well-being of children who are deaf and hard of hearing. Deafness & Education International, 22(No. 2, 139–155). https://doi.org/10.1080/14643154.2019.1635297

Counselman Carpenter, E. A., Meltzer, A. & Marquart, M., (2020). Best practices for inclusivity of deaf/deaf/hard of hearing students in the synchronous online classroom. World Journal of Education, 10(4). doi: 10.5430/wje.v10n4p26

Dettman, S. Chia, Y., Budhiraga, S., Graham, L., Sarant, J., Barr, C., & Dowell, R., (2022).

Understanding typical support practice for students who are deaf or hard of hearing: Perspectives from teachers of the deaf in Australia.  Deafness & Education International, 24(No. 1, 24–28). https://doi.org/10.1080/14643154.2020.1841363

Eichengreen, A., Broekhof, E., Güroğlu, B., & Rieffe, C. (2019). Fairness decisions in children and early adolescents with and without hearing loss. Developmental and Educational Psychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands. doi: 10.1111/sode.12423

Eichengreen, A. & Zaidman-Zait, A. (2020). Relationships among deaf/hard-of-hearing siblings: Developing a sense of self. Journal of Deaf Studies and Deaf Education, 43–54. doi: 10.1093/deafed/enz038

Fitzpatrick, E., Squires, B., & Kay-Raining Bird, (2020). What’s that you say? Communication breakdowns and their repairs in children who are deaf or hard of hearing. Journal of Deaf Studies and Deaf Education, 490–504. doi:10.1093/deafed/enaa010

Hearing Loss Association of America (2023). Let’s take an in-depth look at the three types of hearing loss along with the causes and treatments. Retrieved July 3, 2023, from; https://www.hearingloss.org/hearing-help/hearing-loss-basics/types-causes-and-treatment/

Hettiarachchi, S., Ranaaweera, M., & Disanayake (2021). The effectiveness of using multi-sensory children’s stories on vocabulary development in young deaf and hard-of- hearing children. Deafness & Education International, 23(2), 145–168). https://doi.org/10.1080/146431154.2020.1808275

Knoors, H., & Marschark, M. (2014). Teaching deaf learners: Psychological and developmental foundations. Oxford University Press.

Luckner, J. L., & Sebald, A. M. (2013). Promoting self-determination of students who are deaf or hard of hearing. American Annals of the Deaf, 158(3), 377–386. https://doi.org/10.1353/aad.2013.0024

Nelson, L. H., Anderson, K., Whicker, J., Barrett, T., Muñoz, K., & White, K. (2020). Classroom listening experiences of students who are deaf or hard of hearing using listening inventory for education-revised. Language, Speech, and Hearing Services in Schools, 51(720–733). https://doi.org/10.1044/2020_LSHSS-19-00087

Smith, C., & Allman, T., (2018). Diversity in deafness: Assessing students who are deaf or hard of hearing. Education of the Deaf, Texas Woman’s University, Denton, TX. doi:10.1002/pits.22310