Positive Approaches Journal, Volume 9, Issue 2

Volume 9 ► Issue 2 ► 2020

Communication Assessments for Individuals Who are Deaf/Hard of Hearing and Have Other Disabilities

Jesse Northridge, LCSW
Erin Edwards, BCBA

Abstract

Communication assessments are potentially useful tools for capturing the strengths and needs of individuals who are deaf and have other disabilities. This paper offers insight into strategies for conducting an assessment, an overview of common jargon, the benefits of including formal and informal assessment data and considerations of cultural competence.

Introduction

Individuals with an intellectual disability (ID) or other developmental disability (DD) often present with communication challenges requiring assessment and treatment. Within the diagnosis and treatment of communication challenges, individuals have various strengths and needs. Some may be able to speak fluently with a large vocabulary, but struggle with receptive understanding; others may understand spoken word well, but struggle with effective expressive communication. Some people may be adept at reading social, non-verbal communication and others may miss these cues. These are just a few examples of the complexity in communication among individuals with ID/DD. Communication assessment becomes even more challenging among individuals with additional disabilities, such as sensory impairments (deaf/hard of hearing, deafblindness) as many of the assessment tools are not validated across populations.

Individuals who are deaf and have other disabilities (DWD) such as ID/DD are at a higher risk for mental health, physical health, and cognitive challenges.^1,2 According to data from the Gallaudet Research Institute, approximately 39% of individuals who are deaf or hard of hearing also have an additional disability.³ Completion of a communication assessment and targeted treatment to strengthen communication, is one strategy for developing individualized intervention plans among persons who are DWD.

This article will review basic concepts and strategies for conducting a communication assessment among individuals who are DWD. The first section addresses components to include within the assessment while the second section reviews some of the common terminology used within the literature.

 

Beginning an Assessment

When completing a communication assessment, it is important to consider how and by whom it will be used.^1,4 Assessments can be utilized by teachers to improve instruction techniques. They can be utilized by behavioral health clinicians for the purposes of improving functional independence and psychological wellbeing. They can also be utilized by healthcare providers to improve an individual’s physical health and ability to self-advocate. Families may also utilize the assessment to help secure additional services or benefits, such as through Medical Assistance or the Social Security Administration. The purpose of the communication assessment should be focused on helping the intended audience understand the strengths and needs of the individual within specific contexts.

Neild and Fitzpatrick noted there are factors which may influence an individual’s communication. Among them, the authors identified “(a) degree of hearing loss, (b) primary language used at home, (c) age of on-set, (d) presence of other disabilities, (e) race, (f) gender and (g) socioeconomic status.”⁵⁾ Given the complexity of assessing individuals who are DWD, it is recommended that assessments and recommendations include collaboration with multiple disciplines. ^1,6,7 For example, an individual with physical limitations may struggle if recommended for learning sign language to communicate. Similarly, an individual with visual impairments may not be able to notice visual cues unless presented within their field of vision. The assessment team may include psychotherapists, speech and language therapists, occupational therapists, physical therapists, and physicians. Each of these disciplines can help to gather information regarding the individual’s abilities and needs. They may also be able to offer suggestions for ways of supporting the individual being assessed, such as ways to adapt/modify existing assessment instruments.

According to one article, a communication assessment should “describe the individual’s communication abilities; the skills, needs, culture, and behaviors of their communication partners; and the communications supports and demands presented by different environments.” ⁷ Notable in this recommendation is that not only the individual themselves should be considered, but also behaviors and preferences of the natural supports that they will be communicating with, as well as the contexts in which the individual will be expected to perform the communication skills. The U.S. Office of Special Education Programs and the Perkins School for the Blind have offered guidance on questions and information to include in an assessment. Please see the appendices for some of these examples.

Another format for communication assessments is to utilize dynamic assessments (DA). Dynamic assessment involves both assessment and intervention by placing an “emphasis on the process of learning (the how) rather than the result (the what).”⁸ It involves an initial assessment followed by intervention and follow-up assessments to track the most effective ways of teaching an individual new material. Mann⁸ argues that DA may be a more effective assessment for deaf learners, as it focuses on the individual’s current learning strategies as well as his/her responsiveness to various teaching interventions, rather than simple task performance. However, DA is intended to be an ongoing process over time and may be more appropriate in a school or day program, and not as available in a short-term, clinical setting.

Fundamentals of Communication

Before conducting a communication assessment, it is imperative to understand the jargon associated with the literature. Two of the important terms to understand are expressive and receptive communication. Expressive communication refers to an individual’s ability to send messages to another person. For example, when assessing expressive communication, a clinician may ask the individual to label/name an item, ask for a preferred item or activity or respond to a question. The individual would vocalize, sign or use other Augmentative or Alternative Communication (AAC) to communicate. Alternatively, receptive communication refers to an individual’s ability to understand what another person is communicating. In testing receptive communication, typically a clinician may ask an individual to point to a picture or object that has been named or follow a direction that is given verbally without a model or gesture accompanying it. In assessing individuals who are DWD, the incoming communication will need to be adjusted to match the individual’s strengths and experience. Signing, lip-reading, and gestures may be what the individual understands best; or pictures, symbols, braille, or text may be used for the individual to match to behaviors or responses. When conducting assessments, clinicians must understand that an individual’s abilities within each of these categories may be uneven and that the methods used for communication may be non-traditional (compared with individuals who are not DWD). Often, parental input will be needed to identify and interpret gestures and subtle signals used in the home. This input will help the clinician to understand the individual’s skill level.

Researchers and clinicians may describe communication using the seven levels of communication development.⁹ In Level I (preintentional behavior), individuals (typically young infants) do not communicate voluntarily. However, they are able to share messages of distress to caregivers, who then respond to the individual’s needs. Level II (intentional behavior) involves a transition to movements and gestures that are purposeful in nature (i.e. pushing away unwanted items but is not intended to directly send messages to another person. In Level III (unconventional behavior), individuals use behaviors that may be ignored at a young age (i.e. tugging on people and whining) but are not considered appropriate for older individuals. Level IV (conventional communication) uses non-verbal gestures, movements and possibly vocal intonations to communicate (i.e. waving, pointing). These behaviors are considered socially appropriate across the lifespan. Level V (concrete symbols) is often skipped by individuals without disabilities. However, it involves the use of symbolic gestures or vocalizations (i.e. mimicking the sound of something they desire). Words, both spoken and printed, begin to appear in Level VI (abstract symbols). However, language is typically limited to a singular word at a time. It is not until Level VII (language) that individuals are able to begin forming phrases. For individuals with DWD, it is possible that different types of communication fall across different levels. For example, mands (requests) may be observed at a higher level of speech development than protests (saying no). A thorough assessment may seek to identify types of communication that fall at lower levels, in order to target them to strengthen through intervention.

Furthermore, Taylor’s ¹⁰ article on assessing individuals who are DWD noted there are six parameters of communication assessments. Sensory abilities refer to an individual’s ability to process audio and visual cues. Motor abilities are a person’s abilities (and limitations) of movement when communicating. Of note, this also includes a person’s oral-motor abilities, which impact articulation of vocal speech. Paralinguistic behaviors are non-verbal cues of communication (proximity, body language, facial expressions, etc.) as well as variations in speech (volume, pace, intonation, etc.).   Linguistic abilities refer to an individual’s ability to form, modify and use words. Within this domain, it may be beneficial to note morphological abilities (i.e. prefixes and suffixes), syntax (the sequence and grammar of phrases) and semantics (the intended meanings of phrases). Finally, pragmatic communication refers to how messages are used and interpreted, particularly in varying social contexts. Pragmatic communication can vary widely depending on the communication partners and the settings.¹¹ An assessment across these parameters, with particular attention to the sensory domain (e.g., visual cues, such as orienting and attending to the communication partner), motor domain (e.g. ability for oral motor and/or fine motor for signing), and receptive and expressive paralinguistic behaviors (e.g. use of body language facial expression or touch) may provide information to help match the individual with DWD to a communication system that will best fit their personal strengths.

Formal vs. Informal Assessment

In a study from the United Kingdom, over 76% of speech and language therapists reported using both formal and informal assessments among individuals who are DWD. ¹² Boesch¹³ noted that formal assessments may be needed for differential diagnoses or to secure government benefits. However, informal assessments are likely to provide greater (and possibly more useful) information.

As mentioned above, professionals from a variety of disciplines may utilize a communication assessment to guide and improve interventions. Regardless of an assessment’s eventual utilization, professionals in every domain regularly strive to utilize standardized instruments for their assessment protocols. Standardized instruments can help with a differential diagnosis and compare an individual to same-aged peers. However, formal assessments are rarely validated for use among individuals who are DWD.^4,12

One study from the United Kingdom found that speech and language therapists most commonly chose to utilize three assessments: the Preverbal Communication Assessment, the Affective Communication Assessment and the Checklist of Communication Competence.¹² However, it was also noted that speech and language therapists regularly adapt and modify assessments based on the needs and abilities of the individual.¹ Making these decisions should be done with clinical justifications and with an understanding of how it may alter the results of the assessment. Any modifications to a formal assessment should be noted within the results interpretation.

Given many of the challenges associated with formal assessments, informal assessments may yield more (and higher quality) information.^10,14 An informal assessment generically refers to the use of non-standardized instruments. Clinicians may choose to utilize specific portions of a formal assessment, collect data using a personalized instrument or simply record observational data. During interactions with the individual, the clinician should also strive to utilize the individual’s interests (e.g., preferred topics of conversation, preferred items) to promote engagement and gain better understanding of the individual’s abilities. Regardless of the assessment tool used, it has been recommended that assessments take place in the individual’s natural environments, with observations between the individual and their family members, peers and teachers. ^7,11,14 In fact, failure to do so may yield inaccurate or incomplete data. “Asking students…to perform a skill in settings other than real life removes the contextual cues they rely on to make sense of the task. Artificial environments such as testing rooms may not give accurate information, especially when students have complex disabilities.”¹⁴ Furthermore, “it is preferable to conduct multiple observations in different settings over time, even if the observations are brief.” ¹ Observing these interactions between the person being assessed and their natural supports in context can yield a wealth of information regarding subtle communications that are currently effective for the individual, as well as communications that are not.  For example, in non-speaking children, it is not uncommon to observe a parent or caretaker responding to a need of the child, when to an unfamiliar observer no obvious communication from the child has taken place. In these moments it is helpful for the clinician to explore further, asking the parent or caretaker how they knew what the child needed. Oftentimes, there is a subtle look, sound, gesture, or movement that conveyed a need. Once understood, this subtle communication, understood by only one or two others, can be shaped into a communication that can be understood by a broader population of adults, peers, or caretakers.

Cultural Competence

To someone unfamiliar with deaf culture or unfamiliar with standardized testing instruments, it may be tempting to simply ask that an interpreter aid with translating assessment tools. However, it is important to note that assessments and translations are both filled with complexity.^15,16 For example, an interpreter may not recognize the significance of various words and phrases and may unintentionally convey altered meanings to the individual or the clinician. Similarly, a clinician unfamiliar with deaf culture may misinterpret various nonverbal tactile and body language cues of the individual. Tactile communication, various forms of touch, and tapping behaviors may be used in deaf culture to greet others, protest, direct someone’s attention, or express emotion. Therefore, it is often recommended that assessments be conducted by someone who is both trained in the use of testing materials as well as culturally competent in deaf culture. Interpreters should be used as a last resort. ¹⁷

Conclusion

Communication assessments are both challenging and important for individuals with DWD. It can be crucial to incorporate professionals from a variety of disciplines to collaborate on the assessment. The final product should highlight the individual’s skills and needs. A thorough assessment will incorporate a mixture of both formal and informal assessment tools, though care should be taken when adapting/modifying standardized instruments. Professionals should not only be competent with the administration of these tools but should also be competent in understanding deaf culture. With a thorough communication assessment, professionals can deliver targeted interventions and provide higher-quality services.

Appendix A: Sample Questions from the US Office of Special Education Programs¹

Expressive Communication

1. How does this child make his/ her needs and wants known (body movements, gestures, facial expressions, vocalizations, words, sign language, picture symbols, object symbols, etc.)?
2. Does this child’s expressive behavior appear to be intentional? Is it directed toward a goal? Does it appear that the child anticipates a response to the communication?
3. How frequently does this child communicate?
4. What specific messages or communicative functions does this child express (protests, requests, greetings, etc.)?
5. Under what circumstances is this child most communicative (with whom? when? where?)?
6. Does this child need prompting or support to communicate clearly or consistently? What type of support?

Receptive Communication

1. What types of communicative behavior does this child understand (spoken words, manual signs, gestures, facial expressions, vocal intonation, picture symbols, object symbols, etc.)?
2. What messages or communicative functions does this child appear to understand (directives, greetings, requests, etc.)?
3. Is prompting and support needed for the child to respond to a communication?
4. Who communicates effectively with this child? Are there particular activities in which the child seems most likely to respond?

Social Interaction

1. Does this child enjoy interacting with adults? If yes, under what circumstances?
2. Does this child enjoy interacting with peers? If yes, under what circumstances?

Hearing

1. Is this child able to perceive speech, vocalizations or environmental sounds?
2. Would this child benefit from hearing aids, amplification or noise reduction devices (such as an FM system)?

Vision

1. Is this child able to perceive, discriminate between, and understand visually based symbols for expressive communication? If not, is a tactile expressive system indicated (e.g., object symbols, Braille)?
2. Is this child able to perceive visually based symbols for receptive communication (e.g., picture symbols, sign language, print)? If not, is tactile input required (e.g., tactile signs, object symbols)?
3. What accommodations are needed to help this child perceive visually based communication (positioning of child and partner, illumination, position and spacing of stimuli or symbols, size and color of symbols, etc.)?

Motor/Fine Motor Skills

1. Does this child have the fine motor skills needed to use gestures or manual signs, to indicate choices or to activate expressive communication devices?
2. What accommodations need to be made to allow physical access to expressive and receptive communication systems?

 

Preferences

1. What people, things, and activities does this child prefer?
2. What people, things, and activities does this child dislike?
3. Is this child mostly engaged by objects or by people?
4. Where and when is this child at his/her best?
5. To what extent does this child tolerate direct assistance, such as hand-over-hand or hand under-hand support?
6. What is this child’s primary mode of exploring new things (tactile, visual, oral)?

Temperament

1. Is this child easily excited or passive and quiet?
2. Does this child show sustained attention to tasks or quickly lose interest?
3. Is this child calm or irritable?
4. Is this child sociable or shy?

Does this child accept or reject changes in routines, materials, people, and situations?

Appendix B: Sample Questions from the Perkins School for the Blind¹⁴

1. How does the student demonstrate interest in and awareness of the environment?
2. How does the student demonstrate recognition of familiar things in the environment?
3. Is the student able to learn the names of objects in the environment?
4. Is the student able to name actions in the environment?
5. Does the student comment on activities that occur?
6. Does the student recognize an object as a symbol of an activity?
7. Does the student recognize a picture or partial object as a symbol of an activity?
8. What exposure does the student have to written language (print or braille)?
9. What exposure does the student have to story-time, experience books, or journal activities?
10. Does the student have opportunities to write or draw in various ways?

References

1. Rowland C. Assessing communication and learning in children who are deafblind or who have multiple disabilities. Design to Learn Projects, Oregon Health & Science University; 2009. https://www.designtolearn.com/uploaded/pdf/DeafBlindAssessmentGuide.pdf. Accessed June 24, 2020.
2. Hogan A, Shipley M, Strazdins L, Purcell A, Baker E. Communication and behavioural disorders among children with hearing loss increases risk of mental health disorders. Aust N Z J Public Health. 2011; 35(4): 377-383.
3. Gallaudet Research Institute. Regional and National Summary Report of Data from the 2009-10 Annual Survey of Deaf and Hard of Hearing Children and Youth. Washington, DC: GRI, Gallaudet University; April 2011. https://research.gallaudet.edu/Demographics/2010_National_Summary.pdf. Accessed June 24, 2020.
4. Luckner JL, Bowen S. Assessment practices of professionals serving students who are deaf or hard of hearing: An initial investigation. Am Ann Deaf. 2006; 151(4): 410-417.
5. Neild R, Fitzpatrick M. Overview of assessment for deaf and hard of hearing students. Psychol Schs. 2020: 57: 331-343.
6. Bradham TS, Houston, KT, Diefendorf, AO. Assessing a child with hearing loss: Past, present and future. In: Bradham TS, Houston KT. Assessing Listening and Spoken Language in Children with Hearing Loss. San Diego, CA: Plural Publishing Inc; 2015: 3-18.
7. Brady NC, Bruce S, Goldman A, et al. Communication Services and Supports for Individuals with Severe Disabilities: Guidance for Assessment and Intervention. Am J Intellect Dev Disabil. 2016; 121(2): 121-138.
8. Mann W. Measuring deaf learners’ language progress in school. In: Knoors H, Marschark M. Evidence-Based Practices in Deaf Education. New York, NY: Oxford Scholarship Online; 171-190. doi:10.1093/oso/9780190880545.003.0008.
9. Rowland C. Using the Communication Matrix to assess expressive skills in early communicators. Commun Disord Q. 2011; 32(3): 190-201.
10. Taylor C. Assessment of communication in people with learning disabilities. Advances in Mental Health and Learning Disabilities. 2008 Dec; 2(4): 15-20.
11. Zaidman-Zait A. Assessment of pragmatic abilities in deaf and hard of hearing learners in relation to social skills. In: Knoors H, Marschark M. Evidence-Based Practices in Deaf Education. Oxford Scholarship Online. doi:10.1093/oso/9780190880545.003.0022.
12. Chadwick D, Buell S, Goldbart J. Approaches to communication assessment with children and adults with profound intellectual and multiple disabilities. J Appl Res Intellect Disabil. 2019 Mar; 32(2): 336-358.
13. Boesch M. Best practices for assessing communication skills prior to preference assessments for students with severe developmental disabilities. EBP Briefs. 2014 Sep; 9(3): 1-9.
14. Belote M, Collins M, Edelman S, et al. Assessment. In: Riggio M, McLetchie B. Deafblindness: Educational Services Guidelines. Watertown, MA. Perkins School for the Blind; 2008. https://www.nationaldb.org/media/doc/DESG_Final.pdf. Accessed June 24, 2020.
15. Clark T. Considerations for appropriate assessments with deaf children. Raising and Educating Deaf Children. http://www.raisingandeducatingdeafchildren.org/2015/04/01/considerations-for-appropriate-assessments-with-deaf-children/. Published April 1, 2015. Accessed June 25, 2020.
16. Pizzo L, Chilvers A. Assessment and d/Deaf and hard of hearing multilingual learners: Considerations and promising practices. Am Ann Deaf. 2016 Spring; 161(1): 56-66.
17. Clark TA. Assessment and development of deaf children with multiple challenges. In: Knoors H, Marschark M. Evidence-Based Practices in Deaf Education. New York, NY: Oxford Scholarship Online; 33-58. doi: 10.1093/oso/9780190880545.003.0002
    

Biographies

Jesse Northridge is a licensed clinical social worker for Penn State Health’s Autism Division. He also provides services to the Autism Services, Education, Resources, and Training Collaborative (ASERT), a Pennsylvania initiative funded by the Office of Developmental Programs (ODP). Jesse obtained his master’s degree in social work through Temple University in 2017. He can be reached at jnorthridge@pennstatehealth.psu.edu.

Erin Edwards is a Board-Certified Behavior Analyst (BCBA) for Penn State Health’s Autism Division. She also provides services to the Autism Services, Education, Resources, and Training Collaborative (ASERT), a Pennsylvania initiative funded by the Office of Developmental Programs (ODP). She has been a practicing BCBA since 2008, working across a variety of diagnoses, setting and ages. She can be reached at eedwards@pennstatehealth.psu.edu.