Perspectives on Early Childhood Psychology and Education

Volume 5
Issue 2 Strategies for Early Childhood Article 9
Education of Deaf and Hard of Hearing
Students

February 2023

Assessment of Co-Occurring Disabilities in Young Children Who

are Deaf and Hard of Hearing
Brittany A. Dale

Raschelle Neild

Follow this and additional works at: https://digitalcommons.pace.edu/perspectives

Recommended Citation
Dale, Brittany A. and Neild, Raschelle (2023) "Assessment of Co-Occurring Disabilities in Young Children
Who are Deaf and Hard of Hearing," Perspectives on Early Childhood Psychology and Education: Vol. 5:
Iss. 2, Article 9.
DOI: https://doi.org/10.58948/2834-8257.1064
Available at: https://digitalcommons.pace.edu/perspectives/vol5/iss2/9

This Article is brought to you for free and open access by DigitalCommons@Pace. It has been accepted for
inclusion in Perspectives on Early Childhood Psychology and Education by an authorized editor of
DigitalCommons@Pace. For more information, please contact [email protected].
 Assessment of Co-Occurring Disabilities
in Young Children Who are Deaf
and Hard of Hearing
Brittany A. Dale and Raschelle Neild

Abstract
Overall, the literature is clear that more research is needed on
various assessment techniques for identifying co-occurring dis-
abilities in young children who are deaf and hard of hearing
(DHH). As individualized, norm-referenced assessment measures
are updated to keep up with the changing demographics of
the United States, there appears to be more of an effort to
include children with various disabilities within the standard-
ization samples; however, the communication barriers and
required assessment accommodations remain the most salient
with DHH students. Because accommodations are test-spe-
cific, psychologists must be cognizant of the accommodation
and interpretation procedures of each test they select for an
assessment battery when attempting to determine co-occurring
diagnoses or special education eligibility categories for young
children who are DHH. This article reviews the literature on the
assessment of common co-occurring disabilities in young chil-
dren, including intellectual disability, specific learning disability,
autism spectrum disorder, attention deficit hyperactivity disorder,
and emotional and behavioral disorders.
Keywords: early childhood assessment, deaf students, comorbid conditions
220 Perspectives Volume 5, Issue 2 • Fall 2020

As special education laws have evolved, increased recognition

and value have been placed on early childhood education and early
intervention services (Graham & Shuler-Krause, 2019). The original
special education law, the Education of All Handicapped Children
Act, PL 94-142, passed in 1975. The original act did not mention or
address the needs of infants, toddlers, and their families. The act
was reauthorized in 1986 to include Part C of the Individuals with
Disabilities Education Act (IDEA). Part C established early intervention
services for infants and toddlers and created services for families
of children with disabilities (Katsiyannis, Yell, & Bradley, 2001). The
mandates included in Part C require a comprehensive multidis-
ciplinary evaluation. Once the Individualized Family Service Plan
(IFSP) has been developed, assessments will be ongoing to monitor
progress (IDEA, 2004). Furthermore, once a child reaches their third
birthday, an assessment occurs to determine their eligibility for
continued services under Part B of IDEA when an Individualized
Education Program (IEP) would be developed. These services begin
with preschools housed in the public-school setting and continue
into elementary school and beyond with appropriate identification
of educational needs.

Importance of Early Childhood

Infancy and the early childhood years, including early elementary
school, are critical for development and learning across all domains.
For young children with disabilities, early childhood years are signifi-
cant for numerous reasons and are known for encouraging long-term
success and achievement outcomes for children and their families
(Bruder, 2010). For instance, the earlier the identification of the dis-
ability, the greater the likelihood for benefits from early interventions
and services (Guralnick, 2005). Families and caregivers benefit from
support navigating special education services and meeting the needs
of children with disabilities (Dunst, 2007). Schools and communi-
ties experience a financial benefit because children arrive at school
needing fewer supports and ready to learn (Carta & Kong, 2007).
Assessment of Co-Ocurring Disabilities 221

The benefits of early childhood programs, interventions, and

services have also been noted for children who are deaf and hard of
hearing (DHH; Moeller, 2000; 2007). The Joint Committee on Infant
Hearing (JCIH; 2019) stated that the importance of early intervention
for DHH children was to minimize or prevent delays and encourage
linguistic communication skills, literacy development, and psychoso-
cial well-being. Given development across all domains occurs rapidly
in the first five years of life, there are significant benefits to supporting
a child in each area during this time. In addition to family members,
various professionals contribute to a child’s development, including
educators, physical therapists, speech-language pathologists, and
occupational therapists. To ensure appropriate programs have been
developed, optimal collaboration among all team members occurs,
and adequate progress is being made, assessment is an essential and
critical part of the process. Assessment of preschool-aged children
is complex and challenging, and involves several separate pieces
(Kelly-Vance & Ryalls, 2005).
During preschool and early elementary years, educational
assessment has an essential role in monitoring progress, devel-
oping educational programs, and identifying children for special
education services (Pizzo & Chilvers, 2019). For DHH children and
those administering the assessments, it is a multifaceted process
that has the potential to lead to faulty decision making (Pizzo &
Chilvers, 2019). The lack of appropriate assessment information
can cause DHH children to receive early intervention services that
are inadequate or ineffective (Graham & Shuler-Krause, 2019). For
DHH children, inaccurate assessments can have a lasting harmful
impact, including a misdiagnosis of an additional disability or the
missed diagnosis of a key co-occurring disability for which the
child would benefit from additional supports, accommodations,
and modifications (Pizzo & Chilvers, 2019). Researchers estimate
approximately 40% of children who are DHH have a co-occurring
disability (Guardino & Cannon, 2015), making an accurate assess-
ment with this population extremely important. There is currently
222 Perspectives Volume 5, Issue 2 • Fall 2020

not enough focus on the challenges that arise from assessing DHH
children in the early years (Graham & Shuler-Krause, 2019).
The purpose of this article is to summarize the research dis-
cussing the assessment of common co-occurring disorders in young
children who are DHH. Disability areas covered in this article include
intellectual disability, specific learning disability, autism spectrum
disorder, attention deficit hyperactivity disorder, and emotional dis-
ability. Although an exhaustive review is beyond this paper’s scope,
this information can help guide clinicians and school psychologists,
who may have limited exposure to this low-incidence population,
in their assessment planning.

Intellectual Disability
Cognitive abilities can be accurately measured during the pre-
school years and generally remain stable throughout the lifespan
(Tusing & Ford, 2004). Assessment of cognitive abilities during pre-
school and early elementary school provides a valid and reliable
estimate of a child’s intellectual functioning, paving the way to special
education services if under-developed abilities are identified. These
services are especially crucial for DHH children who are at greater risk
for a comorbid intellectual disability. Approximately 9% of students
who are DHH have co-occurring intellectual disability (Gallaudet
Research Institute, 2011), a higher prevalence rate than exists in
the general population; approximately 1-2% of the US population
are identified with an intellectual disability (Maulik et al., 2011). This
higher incidence of intellectual disability may be accounted for by
shared congenital or prenatal risk factors (Carvill, 2001; Herer, 2012),
but no specific studies have been conducted to evaluate these shared
factors’ effects on the higher prevalence rates.
Separating the assessment of language skills and the assessment
of language-based reasoning skills presents school psychologists with
a significant dilemma when attempting to assess for a comorbid
intellectual disability. Items on verbal subtests historically func-
tion differently within the DHH population (Maller, 1997), causing
Assessment of Co-Ocurring Disabilities 223

school psychologists and other assessment professionals to focus

on fluid reasoning and visuospatial abilities. With the complexity
of cognitive abilities, as defined by modern intellectual theory (i.e.,
Cattell-Horn-Carroll Model), consisting of multiple layers of various
abilities, focusing on a limited scope of abilities may misrepresent
the true cognitive functioning of this population. Given that many
DHH students have language skills through ASL or oral communi-
cation, assessing for language-based knowledge (i.e., crystallized
intelligence) should be considered appropriate; however, standard-
ization of many intelligence tests has not been completed with ASL
translation (Reesman et al., 2014). Even when hearing devices are
utilized and the child’s hearing measures within the normal range,
he or she may still have difficulty discriminating between certain
sounds, adding error into the administration of some verbal sub-
tests (Day, Costa, & Raiford, 2015). When assessing for a co-occurring
intellectual disability, school psychologists should carefully review
the accommodation guidelines of any cognitive ability test they
consider for the evaluation and interpret results in light of these
accommodations.
With the need for psychometrically sound instruments for
assessing cognitive ability in preschool children who are DHH, some
contemporary intelligence tests include recommendations for test
accommodations and interpretation in their manuals or supple-
mental materials. For instance, the Kaufman Assessment Battery for
Children, Second Edition (KABC-II; Kaufman & Kaufman, 2004) and its
recently published Normative Update (Kaufman & Kaufman, 2018) is
a very popular test of cognitive ability for young children due to the
developmentally appropriate visual stimuli utilized throughout the
assessment. The KABC-II and the normative update include individuals
who are DHH within the “other impairment” category of individuals
with disabilities in the standardization samples. This category of “other
impairments” matched the United States school-aged population
prevalence rates of other diagnoses or educational classifications,
thus providing evidence to clinicians that the KABC-II-NU can be
224 Perspectives Volume 5, Issue 2 • Fall 2020

utilized with a DHH student. Furthermore, the nonverbal scales

included in the KABC-II were developed with signing and alternative
forms of administration inherently within the standardized instruc-
tions (Kaufman, Lichtenberger, Fletcher-Janzen & Kaufman, 2005).
Research indicates when the KABC-II is administered by examiners
fluent in ASL, students with moderate to severe hearing loss display
overall intelligence scores similar to their hearing peers (Kaufman &
Kaufman, 2004). The majority of the difference in cognitive abilities
on this measure fell within the categories of auditory memory and
crystalized intelligence, supporting historical findings (see Maller
1997 for a discussion of memory skills in the DHH population).
The Wechsler Intelligence Scale for Children, Fifth Edition, (WISC-V;
Wechsler, 2014) and the Wechsler Preschool and Primary Scale of
Intelligence, Fourth Edition (WPPSI-IV; Wechsler, 2012) are two of the
most widely used tests of cognitive ability for young children. While the
WISC-V excluded children with an uncorrected hearing loss from the
standardization sample, it may be appropriate to assess a student with
the WISC-V who utilizes a cochlear implant, hearing aid, or other assistive
technology. A separate technical report was published and presented
administration and interpretation considerations when choosing to
administer the WISC-V with a child who is DHH (Day, Costa, & Raiford,
2015). Since the normative sample did not include children whose
native language was ASL, and administration was not standardized with
ASL examiners or interpreters, caution should be taken when making
interpretations from adapted administrations. Day, Adams Costa, and
Raiford (2015) provide guidelines for appropriate modifications for
administration and interpretation considerations to the various com-
posites of the WISC-V based on the child’s required communication
modality. For example, administration of the Verbal Comprehension
Index in ASL is not recommended as the mode of delivery and “may alter
the task demand or introduce construct irrelevant variance.” In contrast,
the Visual Spatial, Fluid Reasoning and Processing Speed Indexes are
considered under the category “Administration is possible with little
or no modification” (p. 7, Day, Adams Costa, & Raiford, 2015).
Assessment of Co-Ocurring Disabilities 225

Similarly, these authors provide guidelines for administering

the WPPSI-IV to young children who are DHH (Adams Costa, Day, &
Raiford, 2015). Considerations for the WPPSI-IV reflect those provided
for the WISC-V, including information regarding the standardiza-
tion sample not including children with uncorrected hearing loss.
Additionally, test developers simplified the verbal instructions of
the WPPSI-IV compared to previous versions and included an ancil-
lary Nonverbal Index (NVI). Considered a “language reduced” index
(Adams Costa, Day, & Raiford, 2015), the NVI includes all subtests that
do not require a verbal response. The idea of language reduction
may be misleading to inexperienced assessment professionals, given
the complexity of nonverbal language and the understanding that
ASL is a fluent language. Furthermore, understanding the directions
and many of the nonverbal tasks’ concepts rely on a child’s fund of
language-based knowledge.
Nonverbal cognitive ability tests have long been considered
first choice assessments for students whose native language is not
English. Although they do little to eliminate cultural bias, they are
popular assessments in a “language-reduced” format (Ortiz, Piazza,
Ocha, & Dynda, 2018; Wood & Dockrell, 2010). Various nonverbal
tests of cognitive ability are available, many with instructions for
administration in nonverbal formats (i.e., gestures), varying in the
constructs measured. Some tests estimate cognitive ability through
one matrices-type subtest, whereas others attempt to measure mul-
tiple domains of intelligence. The Universal Nonverbal Intelligence Test
(UNIT; Bracken & McCallum, 1998) contains memory and reasoning
indexes within the symbolic and nonsymbolic domains. Unlike on
more popular tests of intelligence, research has indicated no items
on the UNIT perform differently with children who are DHH through
differential item functioning analysis (Maller, 2000); however, the
factor structure differs between DHH examinees and those of the
standardization sample (Maller & French, 2004). School psychologists
must understand these psychometric properties prior to selecting
this assessment.
226 Perspectives Volume 5, Issue 2 • Fall 2020

The various versions of the Leiter International Performance Scale,

now in its Third Edition (Leiter-3; Roid, Miller, Pomplun, & Koch, 2013),
have been widely utilized within the research to study the cognitive
abilities of children who are DHH. The Leiter-3 includes scales of fluid
intelligence, attention, and memory, and test developers indicate
that the overall IQ is not significantly impacted by the individual’s
language skills (Roid et al., 2013). Standardized with individuals who
were DHH, the Leiter-3 may be a good choice for school psychologists
when assessing for an intellectual disability or to understand the
cognitive strengths and weaknesses of a child who is DHH. When
considering utilizing the Leiter-3 with DHH students, assessment
professionals are encouraged to watch the nonverbal administra-
tion training video provided by test developers to fully understand
the standardized format for nonverbal administration. Test authors
indicated that nonverbal administration must be conducted with
individuals who are DHH since standardization with this popula-
tion occurred in that format (Roid et al., 2013). Khan, Edwards, and
Langdon (2005) found the nonverbal cognitive profiles of children
who were DHH with a cochlear implant for 12 months were equiva-
lent to hearing children on the Leiter-R, the previous version of this
test. Both the hearing and the cochlear implant groups displayed
higher nonverbal intelligence than the non-implanted DHH group.
These results suggest that cochlear implantation enhances the cog-
nitive development of children who are DHH.
Reesman and colleagues (2014) reviewed the available literature
on the current cognitive abilities measures available at the time of
their study and provided a “scorecard” for psychologists to reference
when selecting tests. Specifically, this scorecard indicates whether
test accommodations are addressed and interpretative guidelines
provided, and whether independent literature explores the test’s
functioning with the DHH population. Although their research can be
a useful tool for school psychologists working with the assessments
reviewed, the constant updating of intelligence tests calls for practi-
tioners who work with DHH children to be aware of current literature.
Assessment of Co-Ocurring Disabilities 227

Additionally, with the advances of technology being utilized in assess-

ment (i.e., tablet administration methods), practitioners should be
aware of these alternative assessment measures as potential useful
accommodations for some students who are DHH.

Specific Learning Disability

Kindergarten and first grades are pivotal years for reading inter-
vention to minimize reading problems experienced by a child in the
third grade (Francis et al., 1996). Rapid development in reading skills
occurs at this time, making early identification of reading difficul-
ties crucial in children’s early educational experience. Furthermore,
Qi and Mitchell (2011) argue that children who are DHH are more
likely to be in alternative educational settings where the curriculum
varies from the general population. Therefore, these students are at
a disadvantage when taking standardized tests that assume certain
content is taught at a specific grade level. Given that approximately
8% of children who are DHH are dually diagnosed with a specific
learning disability (SLD; Gallaudet Research Institute, 2011), it is crit-
ical for school psychologists and other assessment professionals
to be abreast of the research regarding identifying SLD in young
children who are DHH. If assessment professionals are not aware of
the unique educational factors that affect children who are DHH that
might influence test performance, they may be more likely to be
identified with a learning disability or be referred for intervention
services within the schools.
Lumped together, SLD and intellectual disability account for the
greatest number of DHH children who present with a co-occurring
disability. Identification of SLD within the DHH population requires
school psychologists and other clinicians to understand the complex-
ity of the sensory system’s impact on learning (Soukup & Feinstein,
2007). Utilizing effective communication strategies, students who are
DHH are expected to progress with typical patterns of achievement
and growth (Pollack, 1997); however, due to multiple factors related
to English language acquisition and multiple disabilities, the overall
228 Perspectives Volume 5, Issue 2 • Fall 2020

academic abilities of DHH individuals remain low compared to that

of their hearing peers. Research over the last 50 years has recognized
this significant difference in academic achievement (Qi & Mitchell,
2012; Wilbur & Quigley, 1975). The reading comprehension grade-
level mean for DHH high school graduates is approximately 4.5 (Holt,
1994; Traxler, 2000), with only 7-10% reading at seventh-grade level
or higher. DHH graduates perform on average at fifth to sixth grade
level in math knowledge. Kritzer’s (2009) research noted that the gap
in math is evident in the preschool years, calling for comprehensive
and accurate assessment of a student’s skills and abilities beginning
in the developmental period.
Popular academic achievement tests utilized by school psychol-
ogists when determining SLD lack normative representation of the
DHH population. Despite this limitation, school psychologists often
have no alternative than to compare data from DHH student assess-
ments to the normative data of the hearing population (Caemmerer,
Cawthon, & Bond, 2016). Additionally, these tests are limited in their
ability to help the school psychologist differentiate if learning diffi-
culties are occurring due to a disability or because of other factors
such as language skills, cultural differences, or instruction that did
not account for the student’s hearing differences. Limited informa-
tion exists regarding the difference in performance on standardized
academic measures between individuals who are DHH and those
who are DHH with co-occurring learning disabilities (Caemmerer
et al., 2016). Caemmerer and colleagues (2016) conducted one of a
limited number of studies comparing the performance of students
who were DHH without a specific learning disability to those who
were dually identified as DHH and SLD. These researchers, utilizing
the popular Woodcock-Johnson Tests of Achievement III (Woodcock,
McGrew, & Mather, 2001), identified math calculation skills as an
area that could help school psychologists distinguish between the
two groups. Specifically, students who were DHH with an additional
learning disability in any academic area were more likely than those
who were DHH without a disability to perform below average on
Assessment of Co-Ocurring Disabilities 229

math calculations. They concluded that math tasks that did not
have a significant language component were the least likely to be
affected by hearing loss (Caemmerer et al., 2016). While more research
is needed in this area, these findings suggest school psychologists
could look to math calculation skills to determine if an actual learning
disability exists.
Assessment through the response to intervention (RTI) approach
for the determination of SLD may potentially be a viable alternative
to standardized academic measures for this population (Gilbertson &
Ferre, 2008). Gilbertson and Ferre (2008) argue progress monitoring
would allow for the development of academic norms for students
who are DHH since comparing them to national norms does not
account for the impact of reduced hearing on these students’ learning
processes. The frequent progress monitoring that occurs within the
RTI system would allow for more guided interventions for students
who are DHH to hopefully close the achievement gap between
their hearing peers. Research on the effectiveness of RTI in identi-
fying co-occurring learning disabilities with the DHH population is
scarce, and more research needs to be done to support its use as
an alternative assessment technique.

Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) is a heterogeneous, neu-
rodevelopmental disorder characterized by deficits in social
communication (including impaired nonverbal communication)
and restricted or stereotyped behaviors (APA, 2013). Given the
disorder’s complexity and heterogeneity, evaluations should be
conducted by clinicians who have received specialized training and
supervision (Wiggins et al., 2015; Zander et al., 2016). Obtaining
an ASD diagnosis for a child who is DHH is further complicated
by the lack of experienced professionals who work with the deaf
population (Dale & Neild, 2020). Finding an assessment professional
with experience in both developmental areas may not be feasible
in some communities.
230 Perspectives Volume 5, Issue 2 • Fall 2020

Further complicating an already complex process are com-

mon factors shared by both ASD and children who are DHH. Some
examples include difficulties with components of language, failing
to respond to one’s name, and some forms of repetitive movements
(Szarkowski et al., 2014). Szarkowski and colleagues (2014) recom-
mend that clinicians look to a child’s preverbal social skills when
making a differential diagnosis. For instance, a child who is DHH
and has ASD will display limited eye contact, struggle with joint
attention, utilize limited gestures, fail to respond to a social smile,
and have under-developed symbolic play skills, all characteristics
clinicians would assess in hearing children.
Little research has been conducted with DHH children in the
assessment of cognitive, adaptive, and other developmental areas
of those who are suspected of comorbid autism spectrum disor-
der (Burns et al., 2016). In a toddler population, Burns et al. (2016)
determined that autism symptom severity, as measured with the
BISCUIT (The Baby and Infant Screen for Children with Autism Traits,
Part 1; Matson et al., 2007) did not differ between the autism group
and the autism with comorbid DHH group. Additionally, results
indicated that the presence of comorbid DHH did not significantly
impact overall developmental functioning in a group of toddlers
suspected of autism spectrum disorder. Although the ASD and DHH
group’s developmental functioning was significantly lower than the
DHH only group, this pattern is comparable to the adaptive func-
tioning of hearing children with autism compared to their typical
hearing peers. The findings of Burns and colleagues (2016) present
important implications for the early identification and assessment
of ASD within the DHH population: (1) measures of ASD severity
and developmental functioning utilized with hearing children may
also be valid with DHH children, and (2) the presence of comorbid
hearing loss does not negatively affect developmental functioning
of children with ASD. In other words, children with comorbid ASD
and DHH display the same pattern of developmental deficits as
hearing children with ASD, and hearing status does not affect the
Assessment of Co-Ocurring Disabilities 231

degree of these deficits. Assessment of ASD requires practitioners

to have a clear understanding of language development in typically
developing children who are DHH. Research suggests that if a child
receives early intervention for their hearing loss, the child would
attain language skills on a similar course to their hearing peers (Ching,
2015); therefore, atypical development in DHH children who received
hearing intervention should alert a practitioner to consider further
evaluation of ASD (Szarkowski et al., 2014).

Attention Deficit Hyperactivity Disorder

According to the Diagnostic and Statistical Manual of Mental
Disorders-5 (APA, 2013), attention deficit hyperactivity disorder (ADHD)
has a “substantial presentation” during childhood. It occurs in about
4% of children of all cultures. Symptoms of inattention (i.e., has
difficulty sustaining attention during class, appears to not listen
during conversations, loses items, is easily distracted, etc.) may be
the dominate feature of the disorder, or it may present with addi-
tional symptoms of hyperactivity or impulsivity (i.e., excessive motor
activity, hasty actions, talking excessively, etc.; APA, 2013). Children
are typically diagnosed in the elementary school years, but parents
may first note increased motor activity during the toddler period.
ADHD appears to have a similar prevalence rate (5.4%) within the
DHH population (Gallaudet Research Institute, 2011). Researchers
argue that many DHH children display symptoms similar to the diag-
nostic criteria for ADHD solely due to the extra cognitive demands
required to evaluate additional sensory stimulation (O’Connell &
Casale, 2004; Parasnis, Samar, & Berent, 2003). For example, a DHH
child may appear easily distracted because they are attempting to
filter out irrelevant background noise or avoid tasks that require
sustained mental effort, not due to ADHD, but because they are
fatigued from tasks requiring prolonged, effortful communication.
Additionally, the necessity to shift attention more frequently
than their hearing peers may be considered an effective strategy
to gain environmental information rather than a deficit in attention
232 Perspectives Volume 5, Issue 2 • Fall 2020

(Oberg & Lukomski, 2011). O’Connell and Casale (2004) provide a

comprehensive list of behaviors common in the DHH population
that may resemble the diagnostic criteria of ADHD. Given this overlap
in symptoms, accurate assessment of ADHD for children who are
DHH is essential.
Although not normed with individuals who are DHH, the Test
of Variables of Attention (T.O.V.A; Leark, Dupuy, Greenberg, Corman,
& Kindeschi, 1996) is a popular tool for identifying ADHD in children
suspected of attention problems regardless of potential comorbid
disabilities. School psychologists should understand the perceptual
sensitivity of the DHH population when choosing computerized
assessments of attention. In an adult sample of individuals who are
DHH without comorbid ADHD, Parasnis, Samar, and Berent (2003)
found the deaf participants had an anticipatory response two to
three times greater than the hearing sample, suggesting increased
impulsivity and poorer detection between targets and non-targets.
The unique sensory perception of individuals who are DHH results
in increased inattention to central visual stimuli (Proksch & Bavelier,
2002), which would impact performance on a computerized mea-
sure through impaired detectability of stimuli. Similar commission
errors on the T.O.V.A. in children are reported in the literature (Dye
& Hauser, 2013). Additionally, DHH children are more distracted by
task-irrelevant information in the peripheral field, further supporting
findings of impaired focus on central stimuli (Dye & Hauser, 2013).
When utilizing computerized tests for the identification of ADHD
with DHH students, school psychologists should be aware of these
unique performance patterns and interpret the results with caution.
Rating scales are also common assessment techniques when
determining an ADHD diagnosis. A comprehensive review of avail-
able attention measures and their utility in diagnosing ADHD in the
DHH population is beyond this paper; however, literature address-
ing the validity of these rating scales with young DHH children is
scarce. The child version of The Behavior Rating Inventory of Executive
Function (BRIEF) rating scale is widely utilized by clinicians and school
Assessment of Co-Ocurring Disabilities 233

psychologists in the assessment of ADHD in children. Oberg and

Lukomski (2011) found that the parent and teacher versions of the
BRIEF were positively correlated in a sample of children who were
DHH. Additionally, the BRIEF findings were positively correlated with
various individual tests of executive functioning, suggesting the
rating scale is a valid assessment tool when evaluating the executive
functioning of DHH children. However, this study did not specifically
utilize this tool for the identification of ADHD, but provides evidence
of its potential utility with the DHH population.

Emotional and Behavioral Disorders

Approximately 3.8% of DHH students receive school-based psy-
chological services nationwide (Gallaudet Research Institute, 2011).
According to the American Psychological Association, the Affordable
Care Act provided funding to allow for schools to expand their men-
tal health services and provide counseling for depression, anxiety,
trauma, and other emotional and behavioral problems commonly
seen in school-aged children (Smith, 2013), providing the potential
for more children to receive services at school. These psychological
services are often included in the IEP of a child with an identified
emotional disability, which occurs in 1.8% of the school-aged DHH
population (Gallaudet Research Institute, 2011). Appropriate iden-
tification of children who are DHH with emotional and behavioral
problems is essential for determining if a co-occurring disability
can be added to an IEP, or if the child would simply benefit from
additional psychological services to improve his or her quality of life.
Assessing for a co-occurring emotional disorder requires that
the school psychologist first understand the impact of communica-
tion on the social-emotional well-being of DHH children. Children
who are DHH are at greater risk for social and emotional problems
due to the greater risk of disruption in these children’s interaction
with their environment (Landsberger, Diaz, Spring, Sheward, &
Sculley, 2014). Research suggests a child who is DHH will experience
impaired communication among the systems that support the child’s
234 Perspectives Volume 5, Issue 2 • Fall 2020

development (parents, schools, culture), thus creating greater

emotional turmoil. These communication problems lead to social
difficulties, and children are more prone to depression and feeling
socially isolated (Theunissen, 2014). Furthermore, children with poorer
communication with their parents display significantly more emo-
tional and behavioral problems compared to their similar-age peers
(van Eldik, Treffers, Veerman, & Verhulst, 2004), and they are at-risk
for developing depression as an adult (Sheppard & Badger, 2010).
Children who are DHH report more depressive symptomology than
their hearing peers, and level of social support predicts depressive
symptomology in individuals who have a hearing loss (Theunissen
et al., 2011).
Assessment for a co-occurring emotional disability often utilizes
objective behavioral rating scales. School psychologists must be
aware of the normative sample of the rating scale that has been
selected. Several popular behavioral rating scales have included
children who are DHH within the standardization samples, and some
provide separate clinical norms for comparison to the population.
Specifically, the Behavior Assessment System for Children (BASC) (cur-
rently in the Third Edition; Reynolds & Kamphaus, 2015) is a popular
set of rating scales utilized in schools to help professionals identify
emotional and behavioral disorders in young children. With par-
ent, teacher, and self-report forms, as well as other observation and
interview forms available, the BASC can be a comprehensive aide in
helping schools identify children with an emotional disability. The
second and third editions, utilized frequently in practice and research,
include a “Clinical Group” for “Hearing Impairment.” These clinical
groups offer a subset of normative data and profiles for comparison.
For example, a school psychologist who obtained a BASC-3 Parent
Rating Scale on a child who is DHH and suspected of a co-occurring
emotional disability can input the student’s score and compare
them to the typical pattern of behavioral functioning exhibited in
the DHH normative sample. However, this practice might not be
suitable for all students who are DHH, given the heterogeneity of
Assessment of Co-Ocurring Disabilities 235

the population (Wood & Dockrell, 2010). Clinicians should be well

informed about the test’s psychometric properties and the individual
characteristics of the student before making assessment decisions.
The Achenbach System of Empirically Based Assessment is another
common evaluation tool more often seen in a clinical setting. The
Child Behavior Checklist (parent version; Achenbach, 1991) and the
Teacher’s Report Form displayed good inter-rater reliability in a sam-
ple of DHH adolescents (van Gent, Goedhart, Hindley, & Treffers,
2007). Within this sample, psychiatrists diagnosed 46% of adolescents
with DSM-classifications, suggesting a high prevalence of emotional
and behavioral disorders in the population. Findings suggest the
Achenbach scales are useful tools in identifying psychopathology
in adolescents who are DHH.

Conclusion
The multiple facets and complexity of deafness combined
with other disabilities pose significant challenges for the individ-
ual and those responsible for meeting the educational needs of
DHH students (Clark, 2019). This article provided a summary of
the research discussing assessments within co-occurring disorders
(intellectual disability, specific learning disability, autism spectrum
disorder, attention deficit hyperactivity disorder, and emotional
and behavioral disorders) in young children in hopes of providing
a better understanding of the needs of DHH children as they relate
to the assessments. It is evident within each area: more research
and focus needs to be placed on the challenges of assessing DHH
children during the early childhood years (Graham & Shuler-Krause,
2019). To have a better understanding and more accurate diagnostic
profile of DHH children with co-occurring disabilities, assessments
should be conducted across all domains by professionals with a
wide range of assessment knowledge related to the modifications,
accommodations, and possible evaluations for this population (Clark,
2011).
236 Perspectives Volume 5, Issue 2 • Fall 2020

Authors Note
Correspondence concerning this article should be addressed to
Brittany A. Dale, Ball State University, Teachers College 723, Muncie,
Indiana 47306. Email: [email protected]

References
Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile.
University of Vermont, Department of Psychiatry.
Adams Costa, E. B., Day, L.A., & Raiford, S.E. (2015). WPPSI-IV technical report #1:
Testing children who are deaf or hard of hearing. NCS Pearson. https://www.
pearsonassessments.com/content/dam/school/global/clinical/us/assets/wppsi-iv/
wppsi-iv-technical-report-1.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed). https://doi.org/10.1176/appi.books.9780890425596
Bracken, B. A., & McCallum, R. S. (1998). Universal Nonverbal Intelligence Test. Riverside
Publishing Company.
Bruder, M. B. (2010). Early childhood intervention: A promise to children and families
for their future. Exceptional Children, 76(3), 339-355.
Burns, C. O., Matson, J. L., Cervantes, P. E., Jiang, X., & Estabillo, J. A. (2016). Hearing
impairment, autism spectrum disorder, and developmental functioning in infants
and toddlers. Journal of Developmental and Physical Disabilities, 28(4), 495-507.
https://doi.org/10.1007/s10882-016-9486-0
Caemmerer, J.M., Cawthon, S.W., & Bond, M. (2016). Comparison of students’ achieve-
ment: Deaf, learning disabled, and deaf with a learning disability. School Psychology
Review, 45, 362-371. https://doi.org/10.17105/SPR45-3.362-371
Carta, J. J., & Kong, N. Y. (2007). Trends and issues in interventions for preschoolers with
developmental disabilities. In S. L. Odom, R. H. Horner, M. Snell, & J. Blacher (Eds),
Handbook of developmental disabilities (pp. 161-180). Guilford Press.
Carvill, S. (2001). Sensory impairments, intellectual disability and psychiatry. Journal of
Intellectual Disability Research, 45(6), 467-483. https://doi.org/10.1046/j.1365-2788.
2001.00366.x
Ching, T. Y. (2015). Is early intervention effective in improving spoken language outcomes
of children with congenital hearing loss? American Journal of Audiology, 24(3),
345–348. https://doi.org/10.1044/2015_AJA-15-0007
Clark, T. (2011). Comprehensive evaluations with children who are deaf or hard of
hearing. In T. Sih, A. Chinski, R. Eavey, & R. Godinho (Eds.), XIAPO Manual of
Assessment of Co-Ocurring Disabilities 237

pediatric otorhinolaryngology (pp. 295-299). Interamerican Association of Pediatric

Otorhinolaryngology (IAPO).
Clark, T. (2019). Assessment and development of children with multiple challenges. In H.
Knoors & M. Marschark (Eds.), Perspectives on deafness: Evidence-based practices
in deaf education (pp. 33-58). Oxford Press.
Dale, B. A., & Neild, R. (2020). The assessment needs of families with children who are
deaf and hard of hearing referred for an autism spectrum disorder. Psychology in
the Schools, 57, 475-484. https://doi.org.10.1002/pits.22328
Day, L.A., Adams Costa, E. B., & Raiford, S.E. (2015). WISC-V technical report: Testing
children who are deaf or hard of hearing. NCS Pearson. https://www.pearsonclinical.
com.au/files/8171450329565.pdf
Dunst, C. J. (2007). Early intervention for infants and toddlers with developmental dis-
abilities. In S. L. Odom, R. H. Horner, M. Snell, & J. Blacher (Eds), Handbook of
developmental disabilities (pp. 161-180). Guilford Press.
Dye, M., & Hauser, P. C. (2013). Sustained attention, selective attention and cognitive
control in deaf and hearing children. Hearing Research, 309, 94-102. https://doi.
org/10.1016/j.heares.2013.12.001
Francis, D. J., Shaywitz, S. E., Stuebing, K. K., Shaywitz, B. A., & Fletcher, J. M. (1996).
Developmental lag versus deficit models of reading disability: A longitudinal, indi-
vidual growth curves analysis. Journal of Educational Psychology, 88, 3–17.
Gallaudet Research Institute. (2011). Regional and national summary report of data from
the 2009-10 annual survey of deaf and hard of hearing children and youth. GRI,
Gallaudet University.
Gilbertson, D., & Ferre, S. (2008). Considerations in the identification, assessment, and
intervention process for deaf and hard of hearing students with reading difficulties.
Psychology in the Schools, 45, 104-120. https://doi.org/10.1002/pits.20286
Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. (2015). BRIEF-2: Behavior Rating
Inventory of Executive Function, 2nd Edition. Psychological Assessment Resources.
Graham, P. J., & Shuler-Krause, E. (2019). Building strong foundations for educational
achievement: Language assessments in early childhood education for deaf and hard
of hearing children. Psychology in Schools, 57, 418-425.
Guardino, C., & Cannon, J. E. (2015). Theory, research, and practice for students who are
deaf and hard of hearing with disabilities: Addressing the challenges from birth to
postsecondary education. American Annals of the Deaf, 160(4), 347–355. https://
doi.org/10.1353/aad.2015.0033
Guarlnick, M. J. (2005). An overview of the developmental system model for early inter-
vention. In M. J. Guarlnick (Ed.), The developmental systems approach to early
intervention (pp. 3-28). Paul H. Brookes.
238 Perspectives Volume 5, Issue 2 • Fall 2020

Hauser, P. C., Lukomski, J., & Samar, V. (2013). Reliability and validity of the BRIEF-A
for assessing deaf college students’ executive function. Journal of Psychoeducational
Assessment, 31(4), 363 –374. https://doi.org/10.1177/0734282912464466
Herer, G. R. (2012). Intellectual disabilities and hearing loss. Communication Disorders
Quarterly, 33, 252-260. https://doi.org/10.1177/1525740112448214
Holt, J.A. (1993). Stanford Achievement Test—8th Edition: Reading comprehension sub-
group results. American Annals of the Deaf, 138(2), 172-175. https://doi.org/ 10.1353/
aad.2012.0684
IDEA (2004). Section 303.321: Evaluation of the Child and Assessment of the Child and
Family. https://sites.ed.gov/idea/reg/c/d/303.321.
Joint Committee on Infant Hearing. (2019). Year 2019 position statement: Principles
andguidelines for early hearing detection and intervention programs. American
Academy of Pediatrics, 4(2), 1-44.
Katsiyannis, A., Yell, M. L., &Bradley, R. (2001). Reflections on the 25th anniversary of the
Individuals with Disabilities Act. Remedial and Special Education, 22(6), 324-333.
Kaufman, A. S., & Kaufman N. L. (2004). Manual for the Kaufman Assessment Battery
for Children—Second Edition (KABC-II) Comprehensive Form. American Guidance
Service.
Kaufman, A., S., & Kaufman, N. L. (2018). Kaufman Assessment Battery for Children,
Second Edition Normative Update. NCS Pearson.
Kaufman, A.S., Lichenberger, E.O., Fletcher-Janzen, E., & Kaufman, N. (2005). Essentials
of KABC-II Assessment. John Wiley & Sons, Inc.
Kelly-Vance, L., & Ryalls, B. O. (2005). A systematic, reliable approach to play assessment
in preschoolers. School Psychology International, 26(4), 398-412.
Khan, S., Edwards, L., & Langdon, D. (2005). The cognition and behaviour of children with
cochlear implants, children with hearing aids and their hearing peers: A comparison.
Audiol Neurotol, 10, 117-126. https://doi.org/10.1159/000083367
Kovacs, M. (1985). The Children’s Depression Inventory (CDI). Psychopharmacology
Bulletin, 21, 995–998.
Kritzer, K. L. (2009). Barely started and already left behind: A descriptive analysis of
themathematic ability demonstrated by young deaf children. Journal of Deaf Studies
and Deaf Education, 14, 409-421. https://doi.org/10.1093/deafed/enp015
Landsberger, S. A., Diaz, D., Spring, N. Z., Sheward, J., & Sculley, C. (2014). Psychiatric
diagnoses and psychosocial needs of outpatient deaf children and adolescents.
Child Psychiatry & Human Development, 45(1), 42-51. https://doi.org/10.1007/
s10578-013-0375-9
Assessment of Co-Ocurring Disabilities 239

Leark, R. A., Dupuy, T. R., Greenberg, L. M., Corman, C. L., & Kindeschi, C. L. (1996).
T.O.V.A. Test of Variables of Attention: Professional manual (Version 7.0) [Computer
software]. Universal Attention Disorders Inc.
Maller, S. J. (1997). Deafness and WISC-III item difficulty: Invariance and fit. Journal of
School Psychology, 35(3), 299-314. https://doi.org/10.1016/S0022-4405(97)00010-1
Maller, S. J. (2000). Item invariance in four subtests of the Universal Nonverbal Intelligence
Test (UNIT) across groups of deaf and hearing children. Journal of Psychoeducational
Assessment, 18(3), 240-254.
Maller, S. J., & French, B. (2004). Universal Nonverbal Intelligence Test factor invariance
across deaf and standardization samples. Educational and Psychological Measurement,
64. 647-660. https://doi.org/10.1177/0013164404263877
Matson, J. L., Boisjoli, J. A., Gonzalez, M. L., Smith, K. R., & Wilkins, J. (2007). Norms
and cut off scores for the autism spectrum disorders diagnosis for adults (ASD-DA)
with intellectual disability. Research in Autism Spectrum Disorders, 1(4), 330-338.
Maulik, P. K., Mascarenhas, M. N., Mathers, C. D., Dua, T., & Saxena, S. (2011). Prevalence
of intellectual disability: A meta-analysis of population-based studies. Research in
Developmental Disabilities, 32, 419–436.
Moeller, M. P. (2000). Early intervention and language development in children who are
deafand hard of hearing. Pediatrics, 106(3), 1-9.
Moeller, M. P. (2007). Case studies: Children. In R. L. Schow & M. M. Nerbonne (Eds.).
Introduction to audiologic rehabilitation (5th ed., pp. 437-466). Allyn & Bacon.
Oberg, E., & Lukomski, J., (2011). Executive functioning and the impact of a hearing
loss: Performance-based measures and the Behavior Rating Inventory of Executive
Function (BRIEF). Child Neuropsychology, 17, 521-45. https://doi.org/10.1080/092
97049.2011.555760
O’Connell, J., & Casale, K. (2004). Attention deficits and hearing loss: Meeting the challenge.
The Volta Review, 104(4), 257-271.
Ortiz, S. O., Piazza, N., Ocha, S. H., & Dynda, A. M. (2018). Testing with culturally and
linguistically diverse populations: New directions in fairness and validity. In D. P.
Flanagan & E. M. McDonough (Eds.), Contemporary intellectual assessment: Theories,
tests, and issues. The Guilford Press.
Parasnis, I., Samar, V. J., & Berent, G. P. (2003). Deaf adults without attention deficit
hyperactivity disorder display reduced perceptual sensitivity and elevated impulsivity
on the Test of Variables of Attention (T.O.V.A.). Journal of Speech, Language, and
Hearing Research, 46, 1166-1183. https://doi.org/1092-4388/03/4605-1166
Pizzo, L., & Chilvers, A. (2019). Assessment of language and literacy in children who are
deaf and hard of hearing. Educational Sciences, 9, 223-238.
240 Perspectives Volume 5, Issue 2 • Fall 2020

Pollack, B. J. (1997). Educating children who are deaf or hard of hearing: Additional
learning problems. ERIC Clearinghouse on Disabilities and Gifted Education. (ERIC
Document Reproduction Service No. ED414666)
Proksch, J., & Bavelier, D. (2002). Changes in the spatial distribution of visual attention
after early deafness. Journal of Cognitive Neuroscience, 14, 687-701. https://doi.
org/10.1162/08989290260138591
Qi, S., & Mitchell, R. E. (2011). Large-scale academic achievement testing of deaf and
hard-of-hearing students: Past, present, and future. Journal of Deaf Studies and Deaf
Education, 17, 1-18. https://doi.org/10.1093/deafed/enr028
Reesman, J., Day, L. A., Szymanski, C. A., Hughes-Wheatland, R., Witkin, G. A., Kalback,
S. R., & Brice, P. J. (2014). Review of intellectual assessment measures for children
who are deaf or hard of hearing. Rehabilitation Psychology, 59, 99-106. https://doi.
org/10.1037/a0035829
Reynolds, C. R., & Kamphaus, R. W. (2015). BASC-3: Behavior Assessment System for
Children, Third Edition. Pearson Clinical.
Roid, G. H., Miller, L. J., Pomplun, M., & Koch, C. (2013). Leiter International Performance
Scale—Third Edition (Leiter-3). Stoelting.
Roth, R. M., Isquith, P. K., & Gioia, G. A. (2005). BRIEF-A: Behavior Rating Inventory of
Executive Function—Adult Version. Psychological Assessment Resources.
Sheppard, K., & Badger, T. (2010). The lived experience of depression among culturally
deaf adults. Journal of Psychiatric and Mental Health Nursing, 17, 783-789. https://
doi.org/10.1111/j.1365-2850.2010.01606.x
Smith, B. L. (2013). Expanding school-based care. Monitor on Psychology, 44(8), 44.
Soukup, M., & Feinstein, S. (2007). Identification, assessment, and intervention strategies
for deaf and hard of hearing students with learning disabilities. American Annals
of the Deaf, 152, 56-62. https://doi.org/10.1353/aad.2007.0014
Szarkowski, A., Mood, D., Shield, A., Wiley, S.E., & Yoshinaga-Itano, C. (2014). A summary
of current understanding regarding children with autism spectrum disorder who
are deaf or hard of hearing. Seminars in Speech and Language, 35, 241-259. https://
doi.org/10.1055/s-0034-1389097
Theunissen, S., Rieffe, C., Kouwenberg, M., Soede, W., Briaire, J., & Frijns, J. (2011).
Depression in hearing-impaired children. International Journal of Pediatric
Otorhinolaryngology, 75, 1313-7. https://doi.org/10.1016/j.ijporl.2011.07.023
Theunissen, S., Rieffe, C., Kouwenberg, M., Raeve, L., Soede, W., Briaire, J., & Frijns, J.
(2014). Behavioral problems in school-aged hearing-impaired children: The influence
of sociodemographic, linguistic, and medical factors. European Child & Adolescent
Psychiatry, 23, 187-196. https://doi.org/10.1007/s00787-013-0444-4
Assessment of Co-Ocurring Disabilities 241

Traxler, C. B. (2000). The Stanford Achievement Test 9th Edition: National norming and
performance standards for deaf and hard-of-hearing students. Journal of Deaf Studies
and Education, 5, 337-348.
Tusing, M. E., & Ford, L. (2004). Examining preschool cognitive abilities using a CHC
framework. International Journal of Testing, 4(2), 91 – 114.
van Eldik, T., Treffers, P. D., Veerman, J. W., & Verhulst, F. C. (2004). Mental health prob-
lems of deaf Dutch children as indicated by parents’ responses to the child behavior
checklist. American annals of the deaf, 148(5), 390-395. https://doi.org/10.1353/
aad.2004.0002
van Gent, T., Goedhart, A., Hindley, P., & Treffers, P. (2007). Prevalence and correlates of
psychopathology in a sample of deaf adolescents. Journal of Child Psychology and
Psychiatry, 48, 950–958. https://doi.org/10.1111/j.1469-7610.2007.10775.x
Wechsler, D. (2014). Wechsler Intelligence Scale for Children, Fifth Edition. NCS Pearson.
Wiggins, L. D., Reynolds, A., Rice, C. E., Moody, E. J., Bernal, P., Blaskey, L., Rosenberg,
S. A., Lee, L., & Levy, S. (2015). Using standardized diagnostic instruments to
classify children with autism in the study to explore early childhood. Journal of
Autism and Developmental Disorders, 45(5), 1271-1280. https://doi.org/10.1007/
s10803-014-2287-3
Wilbur, R. B., & Quigley, S. P. (1975). Syntactic structures in the written language of deaf
students. The Volta Review, 77, 194-203.
Wood, N., & Dockrell, J. (2010). Psychological assessment procedures for assessing deaf
or hard-of-hearing children. Educational and Child Psychology, 27(2), 11-22.
Woodcock, R. W., McGrew, K. S., & Mather, N. (2001). Woodcock-Johnson III Tests of
Achievement. Riverside.
Zander, E., Willfors, C., Berggren, Choque-Olsson, N., Coco, C., Almund, A., Moretto, A.
H., Holm, A., Jifalt, I., Kosieradzki, R., Linder, J., Nordin, V., Olasfottir, K., Poltrago,
L., & Bolte, S. (2016). The objectivity of the Autism Diagnostic Observation Schedule
(ADOS) in naturalistic clinical settings. Journal of European Child and Adolescent
Psychiatry, 25, 769-780.