Assess, Consult, or Refer? How to Handle Testing for Deaf and Hard of Hearing Students

High school graduation should be a time to celebrate: A young person, brimming with promise, is ready to embark. But what if the student isn’t ready—not for college or career or lifelong partnership? What if hearing loss has kept them from acquiring enough language to keep up with ever-increasing academic and social demands? 

“We see this all the time,” says Peter Isquith, PhD, Senior Attending Neuropsychologist at Boston Children’s Hospital. “Imagine the outcomes if you don’t have the ability to think in language or talk in language. What job are you going to do? What relationships are you going to have? The effects can be quite devastating. It sounds extreme, but it’s not unusual.” 

Isquith and his colleagues evaluate dozens of deaf/hard of hearing (D/HH) students every year, conducting research and consulting with providers across the nation.  

“One of the things that happens is that kids with hearing loss of all stripes will end up in an elementary school. They may have a team working with them that includes speech and language pathologist, teacher of the deaf, educational audiologist, and others. Nobody notices just how much information they’re missing,” he says. “The gaps may be filled in by an aide and everything looks okay. Then right around the 5th grade, someone notices that the child can’t read, write, communicate, or socialize as expected. And then we’re in big trouble, because the child is outside the critical window for language development.” 

 Students like these have been immersed in education systems, yet, Isquith explains, “[t]he systems and providers have historically made the decision to give them language exposure but not necessarily language access.” 

The Problem of Language Deprivation  

Language deprivation—the term for denying people adequate access to language—is in the national headlines. The U.S. Supreme Court recently ruled that a case brought by a deaf student, Miguel Perez, could proceed against the Sturgis Public School District in Michigan. The school system denied Perez a diploma after advancing him year after year. Perez and his parents say the school system didn’t support him well enough and misrepresented his progress.

Perez v. Sturgis highlights a growing trend: More and more D/HH students are present in mainstream classrooms without adequate support. “When they lack language,” Isquith says, “it’s an emergency.”

To address the emergency, every student’s progress needs to be assessed early enough to make a difference. But not every practitioner is equipped to conduct such complex evaluations.  When a D/HH student needs an evaluation, how should you decide whether to assess, consult, or refer the student to an expert?  

A Matter of Fairness    

The decision about who should assess a D/HH student comes down to two variables: access and competence. The student must be able to understand how to do the test, and the evaluator must know how to choose the right assessment, deliver it appropriately, and interpret the results accurately. 

Some D/HH students whose hearing loss was identified early, and who had hearing technology early, have a firm language foundation. They may need minimal accommodations for standardized test-taking. For example, they may need a quiet environment and appropriate sound access rather than an evaluation from a signing psychologist. Other students may need more support or different assessment options.  

“Access means I have to make my communication accessible, whether it’s through a cochlear implant, a functional hearing aid, signing, or spoken words combined with sign support. Does the language work for the child?” Isquith asks.  

Hearing technology has advanced, but hearing aids and cochlear implants are not always sufficient. Learning environments need to adjust to the language needs of the child, instead of a student trying to learn in an unsuitable modality. Without access and competence, the process won’t be fair and the results aren’t likely to be reliable.  

To illustrate, Isquith points to some of the problems that arose during the COVID-19 pandemic.  

“There were masks, so there was no speech reading. And there was a plexiglass wall,” he recalls. “I reviewed an evaluation where the person was missing all kinds of information and making lots of mistakes, which were interpreted, sadly, as a dementia, when in fact it was a hearing issue.” 

The Necessary Knowledge   

There’s some question about whether it’s ever appropriate for a person who doesn’t have the language skills and training to give an assessment to a D/HH student. Experts in the field do not all agree. Isquith encourages practitioners to “approach assessment carefully.” 

To assess a D/HH student, Isquith says it’s essential to have foundational knowledge in these areas: 

• The type of hearing loss your student has, along with information about what caused it, how severe it is, what kinds of sounds are accessible, when the hearing loss happened, when it was identified, and what kinds of interventions have been tried 
• Your student’s access to language, including how old they were when they were first exposed to language, which languages they’ve used at home and school, and how good their language access has been in those environments
• Your student’s education, including information about early intervention and preschool, academic performance, and their ability to communicate and socialize
• Your student’s other health conditions, disabilities, delays, or mental health difficulties
• Clinical knowledge of hearing loss types and their potential impacts on language acquisition, cognitive abilities, learning, executive function, and social-emotional development
• Technical knowledge of hearing aids, cochlear implants, and other devices that can improve access to language
• Risk factors for hearing loss
• Language and communication systems, including those used in your student’s parent-child communication 
• Factors associated with resilience  

It’s important to take stock of your background knowledge and the current language functioning of the child before you plan an assessment. Then, he says, “you can decide if you are comfortable seeing a child or not.” 

The Necessary Competencies 

In addition to background knowledge, questions like these can help you decide whether you have the necessary skills to assess a D/HH student: 

• Is conducting this assessment within your professional scope of practice? 
• Can you communicate in a language the student can access? 
• How much training in cross-cultural assessment do you have?
• What other racial, ethnic, religious, or economic identities could intersect with learning differences and hearing loss?
• Do you know which test measures and assessment methods are appropriate for the student?
• Can you appropriately adapt assessments to meet the student’s needs? 

The NASP position statement further states that those serving D/HH students are “responsible for confirming that the samples and validity studies for any assessment they use are aligned with the student’s background” (NASP, 2020). 

“That’s a pretty heavy responsibility,” Isquith says.  

Consulting, Referring, and Working with Interpreters 

If you don’t yet have the background knowledge or skills to assess a D/HH student on your own, it’s important to consult with or refer to a professional who does. Your state school for the deaf is a good resource to help you locate an expert who may be able to consult with you or do the evaluation. 

“Using an interpreter is possible, but it’s hard. It takes some work,” Isquith points out. “You have to work with the interpreter to find out exactly what they’re doing. You’ll need to tell them in advance, ‘This is what I want you to do and here are the potential problems.’” 

When working with an interpreter, you’ll need to 

• avoid most verbal measures, since they will be hard to interpret; 
• review security and confidentiality processes; 
• ask for both a word-for-word interpretation and cultural meaning interpretation; and 
• de-brief thoroughly after the assessment. 

Isquith also recommends carefully documenting the steps you take during consultation. And whether you assess, consult, or refer—be prepared for a more comprehensive evaluation.

“We should assess more than we would for a typically hearing child,” recommends Isquith. “For example, I routinely give two estimates of cognitive ability, just to make sure I have some agreement. Even though things seem to be going well in some areas, such as spatial reasoning or motor speed, we should double check. We shouldn’t fall prey to looking only where the light is brightest.”

To make sure an evaluation is as complete as possible, it’s important to work with a team of practitioners with varied expertise. The reason for taking such a careful and thorough approach, he says, is that “it’s too easy to make a mistake that will be costly for the child or the family or for you, in the end.” 

Key Messages  

As the number of D/HH students in mainstream classrooms increases, more and more school-based professionals will be involved in making assessment decisions. Taking stock of your own background knowledge and competencies can help you determine whether to assess, consult, or refer the student in your care.

“We need to be thinking about meeting the needs of all students,” Isquith emphasizes. “In the last 30+ years working with the Deaf and Hard of Hearing Program at Boston Children’s Hospital where we have this very unique team, we’ve gone from the majority of kids as signers to the majority of kids as talkers, through the advent of advanced hearing technologies such as cochlear implants. A lot of these kids are not being seen by specialists…but there are still special considerations that we need to think about for assessment.”

Educators and clinicians must make sure D/HH students are carefully, competently assessed early enough to prevent language deprivation. Doing so will mean that more students can spend their school years building skills and friendships. And more students can leave school ready for all the possibilities on the other side of the graduation stage.  

• Learn more about the Language Equality and Acquisition for Deaf Kids (LEAD-K) legislation being studied and adopted across the U.S. 
• Explore learning opportunities through the Laurent Clerc National Deaf Education Center at Gallaudet University.  
• Find out more about the services offered by the Boston Children’s Hospital Deaf and Hard of Hearing Program.