LSHSS
Research Article
Confidence of School-Based Speech-Language Pathologists and School Psychologists in Assessing Students With Hearing Loss and Other Co-Occurring Disabilities Monica P. Muncy,a Sarah E. Yoho,a and Maryellen Brunson McClainb
Purpose: This study assessed the confidence of speechlanguage pathologists (SLPs) and school psychologists (SPs) in working with children with hearing loss (HL) and other co-occurring disabilities. Professionals’ opinions on barriers to and importance of interdisciplinary collaboration were also of interest. Method: A 59-item online survey was distributed to SLPs and SPs in the United States through state professional organizations and social media posts. A total of 320 respondents completed the survey and met criteria. Perceptions of confidence across 5 different skill set types were assessed, along with experiences and attitudes concerning professional training and interdisciplinary collaboration. Results: A 2-way analysis of variance revealed significant main effects of profession and skill set type on professionals’ confidence in assessing a student with HL and other co-occurring disabilities, as well as their confidence in determining the etiology of a student’s difficulties. Results
from a multiple linear regression revealed the number of students worked with who have HL and the amount of training in graduate school as significant predictors of confidence in both aforementioned skill set types. Results indicate that respondents value interdisciplinary collaboration but that time and access to other professionals are barriers to collaboration. Conclusions: Results of the current study indicate that many school-based SLPs and SPs have insufficient training or experience in working with students who have HL and other co-occurring disabilities. Limited training and experience with this unique population among practitioners have the potential to affect the quality of services provided to these students and thus need to be addressed within the school system and the fields of school psychology and speechlanguage pathology. Supplemental Material: https://doi.org/10.23641/asha. 7772867
M
children as they are highly involved in providing services to students in special education, regardless of disability type. Given the likely involvement of SLPs and SPs in working with this population, these professionals need to be experienced and comfortable in evaluating and interacting with students with HL, especially those with other co-occurring disabilities, as these students present with unique challenges. It has been well documented that students with HL experience more difficulties in school compared to their peers with normal hearing (Culbertson & Gilbert, 1986; Easterbrooks, Lederberg, Miller, Bergeron, & Connor, 2008; Harrington, DesJardin, & Shea, 2010). Areas of difficulty may include language and speech skills (Briscoe, Bishop, & Norbury, 2001; Wake, Hughes, Poulakis, Collins, & Rickards, 2004), social interaction (Cappelli, Daniels, Durieux-Smith, McGrath, & Neuss, 1995), psychological development (Hogan, Shipley, Strazdins, Purcell, & Baker, 2011; Van Eldik, 2005), and academic achievement (Bess, Dodd-Murphy, & Parker,
any children who have hearing loss (HL) also have other co-occurring disabilities, such as autism spectrum disorder (ASD), attention-deficit/ hyperactivity disorder (ADHD), or specific learning disabilities (Gallaudet Research Institute, 2010). School-based speechlanguage pathologists (SLPs) and school psychologists (SPs) are often the professionals who work most closely with these students. This may be partly due to an underrepresentation of educational audiologists in the school system (DeConde Johnson & Seaton, 2011). In particular, SPs work with these
a
Department of Communicative Disorders and Deaf Education, Utah State University, Logan b Department of Psychology, Utah State University, Logan Correspondence to Sarah E. Yoho:
[email protected] Editor-in-Chief: Shelley Gray Editor: Dawna Lewis Received August 27, 2018 Revision received October 4, 2018 Accepted October 12, 2018 https://doi.org/10.1044/2018_LSHSS-18-0091
Disclosure: The authors have declared that no competing interests existed at the time of publication.
Language, Speech, and Hearing Services in Schools • 1–13 • Copyright © 2019 American Speech-Language-Hearing Association
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
1
1998). These difficulties vary in type and severity for each child, even for those who have similar audiologic disabilities. Approximately 38.9% of children with HL have other disabilities or disorders (Gallaudet Research Institute, 2010). Although HL alone presents many obstacles for the affected child, these challenges only compound and expand when co-occurring disabilities exist. Children who struggle with both ASD and HL face greater communication struggles than children with either one of those disabilities in isolation (Biddle, 2014; Vernon & Rhodes, 2009). In addition, cooccurring HL and intellectual disabilities are related to an increased risk of behavioral issues (Buskermolen, Hoekman, & Aldenkamp, 2012). Co-occurring disabilities also exacerbate educational performance issues; for example, students with both ADHD and HL may face difficulties focusing in class, which could be due to either ADHD, a failure to pick up on auditory cues due to HL, or both (O’Connell & Casale, 2002; Schum, 2003). Not only can co-occurring disabilities make academics and social interaction complicated for students with HL, co-occurring disabilities can also make assessment, diagnosis, and treatment of these students more complex. If a student has HL, assessment procedures for disabilities such as ASD, ADHD, and so forth must be adjusted to fit the possible limited language and communication skills of the student with HL, while remaining standardized. Schum (2003) discussed various assessments that can be utilized with the population of students with HL to test for individual disorders that are commonly comorbid with HL. Such assessments consider the fact that students with HL may not be able to complete verbal tasks and may have to be tested using other methods, such as nonverbal tasks. Professionals who administer assessments to students with HL need to understand and effectively deliver such tests in a way that will make sense to the child without invalidating results (Indiana Center for Deaf and Hard of Hearing Education, 2013). Although some may believe that a possible solution is to administer assessments using American Sign Language or other visual languages, Schum warns that the iconicity of sign language may deem it inappropriate for use in language and auditory processing assessments. The iconic nature of certain signs in American Sign Language may give the child cues as to the meaning or use of a word that would not be available if presented verbally. One way to ensure assessments are carried out in an optimized way for students with HL and other co-occurring disabilities is to ensure all professionals with relevant expertise are involved in the process. Ideally, assessments of students with HL and other co-occurring disabilities should be highly interdisciplinary in nature, particularly as interdisciplinary-based assessments and treatment plans lead to a more complete understanding of the child as more than just the results from each individual test (Roush & Wilson, 2013). These interdisciplinary teams should often include an educational audiologist, an SLP, and an SP. Unfortunately, this may not be occurring in practice as often as it should. However, both SLPs and SPs do contribute to the assessment and treatment of students with HL, although
2
each professional may play a different role. SPs are responsible for assessing the intellectual, cognitive, social, emotional, and behavioral skills of students and helping them to learn and grow in these areas (National Association of School Psychologists, 2017). Braden (1992) found that, although there are plenty of adapted intellectual assessments available for use with children with HL, this information may not be well disseminated to SPs. Although SPs may not be the main assessor of a child’s language skills, they may be relied upon heavily for assessing other areas of functioning, such as nonverbal cognitive or memory skills (Schum, 2003). SLPs play a significant role in the assessment of language and literacy skills of children with multiple disabilities (Luckner & Bowen, 2006). Although they may receive more education about HL during their educational training than SPs, there are likely areas in which SLPs are uncertain of testing procedures for students with HL or interpretation of assessment results. A study conducted by Richburg and Knickelbein (2011) revealed an alarming conclusion: Some SLPs do not have training or even a rudimentary knowledge of certain audiologic concepts, despite receiving a degree in communication disorders from an accredited institution. Further studies have found that SLPs working with children who have HL are not extremely confident in skill areas more directly related to the child’s HL (Harrison et al., 2016; Page et al., 2018). Unfortunately, even without sufficient training, SLPs are often the first professionals to be contacted to manage the case of a child with communication difficulties, including HL. However, for children with HL, educational audiologists should be the primary professional responsible in these cases. Currently, there is lack of research that shows the amount of time that is dedicated within SLPs’ and SPs’ graduate programs to teaching concepts related to HL or working with students who have HL and other co-occurring disabilities. Although some information is available about the subjective perceptions of SLPs on their preparedness to work with students with HL (Richburg & Knickelbein, 2011), there is not much existing information on the perceptions of SPs. A better understanding of these issues could lead to adjustments in educational programs to better prepare graduates to assist children with HL and other comorbid disabilities, which would, in turn, benefit the children being served by these professionals in the schools. To address this gap in the literature, the current study utilized a nationwide survey to answer three research questions related to this topic.
Research Questions Research Question 1 What are SLPs’ and SPs’ experiences and confidence in assessing children with multiple disabilities, including HL? Researchers examined (a) differences in self-reported confidence across professional discipline and skill set type and (b) predictors of practitioners’ confidence in performing an assessment for a student who has HL and other co-occurring disabilities and confidence in distinguishing
Language, Speech, and Hearing Services in Schools • 1–13
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
academic and developmental concerns due to HL from those due to other co-occurring disabilities. Research Question 2 What are SLPs’ and SPs’ experiences and attitudes regarding interdisciplinary collaboration? Specifically, researchers examined (a) participants’ self-reported experience with interdisciplinary collaboration and (b) participants’ attitudes on the importance of interdisciplinary collaboration. Research Question 3 What additional training do these professionals feel would be potentially useful in further interactions with children who have co-occurring HL and other disabilities? Researchers examined (a) what training participants received and (b) what training they wished they had received.
Method Participants A total of 320 school-based SPs (n = 146) and SLPs (n = 174) participated in the current study. Four hundred thirty-six surveys were started, but 116 were omitted from analyses due to incomplete responses or participants not meeting study criteria (i.e., not SPs or SLPs, SPs or SLPs not practicing in the school setting).
Instrument The survey was created by the authors and included 59 questions. After the creation of the survey, the instrument was reviewed and validated by an individual with experience as a school-based SLP and an individual with experience in school psychology. One qualitative question also allowed participants to express their opinions about the importance of interdisciplinary collaboration when working with this population of students. Participants completed the survey online through REDCap (Research Electronic Data Capture; Harris et al., 2009). A copy of the survey can be found in Supplemental Material S1.
Procedure Following approval from the university institutional review board, the state organizations for school psychology and speech-language pathology (often a joint organization with audiology) were contacted by the first author and asked to distribute the study information and survey to their members. Study information and the survey link were also posted on various forums and social media pages. Participants were also encouraged to forward the link to relevant colleagues. Following consent, participants completed the questionnaire.
Data Analyses Quantitative Methods Quantitative analyses were used to evaluate all research questions, except for Part b of Research Question 2. Descriptive statistics were used to define participant characteristics.
A two-way analysis of variance (ANOVA) was used to examine Research Question 1a and compared differences in confidence levels between SLPs and SPs. Five questions asked about the participants’ confidence in performing different skill set types involved with the assessment process. The participants answered using a sliding scale, from 0 to 100, with 0 = not confident at all and 100 = extremely confident. There were five different skill set types that were assessed in the current study: (a) confidence in knowing if a child’s hearing aids are working, (b) confidence in troubleshooting a malfunctioning hearing aid, (c) familiarity with personal frequency modulation (i.e., FM) devices, (d) confidence in performing an assessment for a child who has HL and other co-occurring disabilities, and (e) confidence in distinguishing academic and developmental concerns due to HL from those due to other co-occurring disabilities. The independent variables for the ANOVA were the areas of confidence assessed and the profession of the respondents. The dependent variable was the self-reported confidence level on the 0–100 scale. Multiple linear regressions were used to answer Research Question 1b and determine predictors of confidence values. Specifically, we chose to examine predictors of confidence for the two more broad skill set types of confidence in performing an assessment for a student with HL and other co-occurring disabilities and confidence in distinguishing the etiology of an academic or social concern. The four predictor variables were chosen because it was believed they would have an influence on the level of confidence the professionals had for the various skill set types. In the first multiple linear regression model, the outcome variable was self-reported confidence in performing an assessment for a student with HL and other co-occurring disabilities, and the four predictor variables used in the model were years worked in the school setting, number of students worked with who have HL, amount of HL training received in graduate school, and profession (SLP or SP). In the second multiple linear regression model, the outcome variable was self-reported confidence in distinguishing the etiology of an academic or social concern. The four predictor variables used in the model were the same variables used in the first regression model. Qualitative Methods The one open-ended question in the survey probed the respondents’ opinions on the importance of interdisciplinary collaboration. The question asked, “Please describe your perspective on the importance and role of interdisciplinary collaborations to assess students with multiple disabilities (one of which is HL) in school settings.” Thematic analysis was used to analyze respondents’ responses to this question. According to Braun and Clarke (2006), thematic analysis is a qualitative data analysis method used to identify and report recurring themes that are present within a data set. For this analysis, participant responses were grouped together across responses of SLPs and SPs to evaluate a holistic picture of school-based practitioners’ attitudes on collaboration. Each respondent’s answer was entered into
Muncy et al.: Confidence Hearing Loss Co-Occurring Disabilities
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
3
the online software Dedoose Version 7.0.23 (2017) for easy coding and organization. Two researchers collaboratively analyzed each excerpt to decide how the quote should be coded. Ambiguous excerpts were discussed by both researchers to determine the most accurate code, but most responses were coded by only one researcher. No responses were omitted from the analysis. After the coding process was complete, overarching (primary) themes and subthemes were developed by the authors to present a broad picture of the responses.
Results The number of participants across groups, SLPs (n = 174) and SPs (n = 146), was not significantly different, χ2(1, N = 320) = 2.45, p = .118. The majority of participants were White (92.5%) and female (92.8%), who were 41.9 years old, on average, with an average of 13.5 years of experience working in schools (SLP: M = 14.5, SD = 10.3; SP: M = 12.4, SD = 9.58). SLPs represented 28 states, whereas SPs represented 15 states. Figure 1 depicts the states from which survey responses were gathered. Additional participant demographic information can be found in Table 1.
Research Question 1: Experience and Confidence in Assessing Students With HL and Other Disabilities Research Question 1a Mean confidence levels for the various skill set types can be found in Table 2. Results from the two-way
ANOVA yielded significant main effects for both skill set type, F(4, 1584) = 73.4, p < .001, and professional discipline, F(1, 1584) = 233.4, p < .001. A significant interaction effect was also found, F(4, 1584) = 12.6, p < .001. Post hoc testing using Tukey’s honestly significant difference revealed significant differences between the professions in all but two of the comparisons between various confidence areas. Specifically, SLPs had significantly higher confidence in areas of whether or not a hearing aid is working, how to troubleshoot a malfunctioning hearing aid, and familiarity with frequency modulation systems. Table 3 provides all comparison statistics, and Table 4 displays the post hoc results. Figure 2 shows the interaction plot. Research Question 1b The two multiple linear regression analyses sought to determine predictors of practitioners’ confidence in two different skill set types. In the first analysis, which had an outcome variable of confidence in performing an assessment for students with HL and other co-occurring disabilities, regression results indicated that four predictor variables explained 24.5% of the variance (R2 = .245), F(9, 304) = 12.3, p < .001. However, only two of the variables were found to be significant, and they accounted for the majority of the variance in the model (R2 = .233). The number of students with HL the professional had worked with (B = 35.494, p < .001) and the amount of HL-related training the professional received in graduate school (B = 17.515, p = .004) significantly predicted confidence in performing an assessment for a student with HL and other co-occurring disabilities. In
Figure 1. Map of states from which responses were received, broken down by respondents’ profession. SLP = speech-language pathologist; SP = school psychologist.
4
Language, Speech, and Hearing Services in Schools • 1–13
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Table 1. Demographic characteristics of participants given in percentage (N = 320). Characteristic Gender Female Male Prefer not to answer Race American Indian/Alaska Native Asian Black/African American Latino/a White Multiracial Other Highest degree earned Bachelor’s Master’s Specialist Doctoral Other School setting Public Private Charter Location Urban Suburban Rural Don’t know Number of children worked with who have HL 0 1–9 10–20 > 20
SLP (n = 174)
SP (n = 146)
96.6 2.9 0.6
88.4 11.0 0.7
4.6 0.6 5.2 1.7 92.0 1.7 0.0
0.7 1.4 1.4 2.1 93.2 1.4 2.1
0.0 96.6 0.0 2.9 0.6
1.4 21.9 58.9 15.8 2.1
96.0 3.4 0.6
95.9 0.7 3.0
22.4 42.5 36.8 2.3
23.3 49.3 33.5 0.7
1.7 64.0 19.0 15.5
2.7 76.7 9.6 11.0
Confidence type Profession Interaction Residuals
df
Mean square
F
p
196,739
4
49,185
73.4 < .001
156,466 33,704 1.06e + 6
1 4 1,584
156,466 8,426 670
233.4 < .001 12.6 < .001
Research Question 2: Attitudes About Interdisciplinary Collaboration
Table 2. Mean confidence level (on a scale from 0 to 100) for various skill set types related to assessment and treatment of students with hearing loss and other co-occurring disabilities.
HA functioning check M SD HA troubleshooting M SD FM familiarity M SD Assessment of student with HL and co-occurring disabilities M SD Determining etiology of academic or social concerns M SD
Sum of squares
the second analysis, which had an outcome variable of confidence in distinguishing the etiology of an academic or social concern, results indicated that the same four predictor variables explained only 17% of the variance (R2 = .169), F(9, 310) = 8.21, p < .001. Again, only two of the variables were significant and accounted for a majority of the variance found in the model (R2 = .166). The number of students with HL the professional had worked with (B = 37.539, p < .001) and the amount of HL-related training the professional received in graduate school (B = 11.542, p = .047) significantly predicted confidence in the ability to distinguish academic and developmental concerns due to HL from those due to other co-occurring disabilities.
Note. SLP = speech-language pathologist; SP = school psychologist; HL = hearing loss.
Confidence area
Table 3. Two-way analysis of variance comparison statistics for participants’ self-reported confidence in various skill set types related to assessing students with multiple disabilities including hearing loss.
SLP
SP
48.1 29.4
17.8 23.3
38.4 30.4
10.3 16.8
49.9 29.0
26.8 27.2
57.9 24.3
47.6 26.7
56.6 22.9
49.0 24.6
Note. SLP = speech-language pathologist; SP = school psychologist; HA = hearing aid; FM = frequency modulation; HL = hearing loss.
Research Question 2a Seventy percent of SLP respondents indicated that they regularly or almost always collaborate with professionals from other disciplines, whereas 30% indicated that they collaborate occasionally, rarely, or never. For SP respondents, 73% of participants indicated that they collaborate regularly or almost always, and 27% of participants reported that they collaborate occasionally, rarely, or never. Special education teachers and audiologists were the most common professionals that participants reported collaborating with when working with students in this population. SLPs and SPs reported commonly collaborating with one another. Figure 3 shows with which professionals the participants report they commonly collaborate. An additional area of interest was what barriers prevent collaboration. “Limited time” and “limited access to other professionals” were the two most common barriers for both SLPs and SPs. Notably, 27% (n = 47) of SLPs and 36% (n = 53) of SPs reported that they do not experience any barriers to collaborating with professionals from different disciplines. Figure 4 displays the frequency of responses for each barrier presented as an option in this study. Research Question 2b Qualitative thematic analysis was used to analyze participant responses regarding their perceptions on the importance of interdisciplinary collaborations in providing school-based services to this unique population. Two
Muncy et al.: Confidence Hearing Loss Co-Occurring Disabilities
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
5
Table 4. Post hoc results of differences in confidence levels across different skill set types between the two professions (reference group: speech-language pathologist). Mean difference
SE
t
pTukey
30.260 28.079 23.126 10.344 7.642
2.91 2.91 2.91 2.93 2.91
10.413 9.663 7.958 3.528 2.630
< .001 < .001 < .001 .016 .204
HA working HA troubleshooting FM familiarity Performance of assessment Determining etiology of difficulty
Note. HA = hearing aid; FM = frequency modulation.
overarching (primary) themes emerged: reasons interdisciplinary collaboration is important and barriers encountered during interdisciplinary collaboration. Within each primary theme, three subthemes emerged with varying amounts of codes classified under each secondary theme. A full count of the themes and corresponding codes can be found in Table 5. Primary Theme 1: Importance of interdisciplinary collaboration. Respondents described why they felt interdisciplinary collaboration is important in situations where a student has HL and other co-occurring disabilities. The three themes in this category were (a) Student Outcomes, (b) Practitioner Knowledge and Perspectives, and (c) Ideal Assessment Approaches. Student outcomes. Thirty-four percent of the responses under the primary theme Importance of Interdisciplinary Collaboration were coded as the subtheme Student Outcomes. Student Outcomes focused on improving the student
educational outcomes or engaging in practices that are educationally optimal for the student. Within Student Outcomes, four codes emerged: Best for the Child, Influencing Child Outcomes, Meeting Student’s Needs, and Whole Picture. The first code, Best for the Child, described collaboration as being an integral part of the assessment process, which produces results that are best for the child. Influencing Child Outcomes discussed the effect that interdisciplinary collaboration could have on the outcome of a student with HL and other co-occurring disabilities. An example of a response under the Influencing Child Outcomes code is, “Collaborating with the team (including the parents) is the best way to make progress with the student in an academic setting and providing tools for when the student is out of an academic setting.” Meeting Student’s Needs reviewed the significance of not only identifying the student’s needs, strengths, and weaknesses but also developing individualized plans that incorporate all fields to best meet the needs
Figure 2. Confidence level in each of the five skill set types as a function of respondents’ profession. SLP = speech-language pathologist; SP = school psychologist; HA = hearing aid; FM = frequency modulation.
6
Language, Speech, and Hearing Services in Schools • 1–13
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Figure 3. Frequency of response selection for the question: “When assessing students with multiple disabilities (including hearing loss), please identify the professionals in which you frequently collaborate (choose all that apply).” Responses are broken down by profession of respondents. SLP = speechlanguage pathologist; SP = school psychologist; Ed. = education.
Figure 4. Frequency of response selection for the question: “Please identify any barriers you feel may impact your ability to collaborate with other disciplines during school-based evaluations for students with disabilities (select all that apply).” SLP = speech-language pathologist; SP = school psychologist.
Muncy et al.: Confidence Hearing Loss Co-Occurring Disabilities
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
7
Table 5. Total counts of subthemes and codes within subthemes for the open-ended question probing respondents’ opinions on the importance of interdisciplinary collaboration. Importance of Interdisciplinary Collaboration Practitioner Knowledge and Perspectives (151) • Experience/Knowledge (65) • I Lack the Knowledge (33) • Perspectives (30) • Not Independent (12) • Learning New Information (9) • Outside Agencies (2)
Student Outcomes (123) • Influencing Child Outcomes (47) • Whole Picture (37) • Meeting Student’s Needs (22) • Best for the Child (17)
Ideal Assessment Approaches (92) • Understanding Impact of Disability (34) • Benefits Evaluation Process (32) • Making Informed Decisions (15) • Helpful Process (11)
Lack of Availability (6) • Professional Not Available (5) • Collaboration Unavailable (1)
Interpersonal Complications (5) • Does Not Want To (3) • Discipline Not Valued (1) • Unsure of Process (1)
Barriers to Collaboration Lack of Time (11) • Not Enough Hours (8) • Heavy Workload (3)
of each student. The importance of seeing the whole child and not just bits and pieces of his or her diagnoses was covered by the code Whole Picture. The following response was coded as Whole Picture: “I always think the interdisciplinary approach is best. It’s important to get input from all the professionals involved with the individual in order to get the most complete and balanced snapshot of the student.” Practitioner knowledge and perspectives. Forty-one percent of the responses under the theme Reasons Interdisciplinary Collaboration Is Important were coded as the subtheme Practitioner Knowledge and Perspectives. This subtheme covers differences in experience, knowledge, and training that exist between different professionals on the evaluation team. Within this theme, six codes emerged. Experience and Knowledge articulated the fact that other professionals had knowledge of a field that is different than what others bring to the table. This code can be exemplified well with the following response: “Such collaboration allows for wellversed informative practices among various related fields as they offer different areas of expertise and quite frankly, the more ideas/brainstorming/perspectives, the better.” This code was commonly found in conjunction with the code I Lack the Knowledge, which described the admission that other professionals have knowledge that the individual respondent does not. The following quote is an example of this code: “I would not want to assume that I knew all the answers in all areas being assessed and would want to defer to a professional that did.” This is different than the Experience/Knowledge code insofar as the researchers believed there was a fundamental difference between acknowledging the professional experience of others and being able to admit that you are simply not knowledgeable about every possible field. The code Learning New Information expressed the value of interdisciplinary collaboration because it provides professionals with an opportunity to gain knowledge from other professionals, and it is exemplified by the quote “I learn a lot from other professionals that I am then able to use when consulting on cases in the future.” The fact that
8
no one professional can perform all necessary assessments and procedures on his or her own was covered by the code Not Independent. Outside Agencies explained the importance of not only working with professionals within the school system but also bringing in providers who interact with a child through other organizations. The code Perspectives brought up the fact that every person and professional involved in a case view the facts through a different lens and thus may have different ideas about how to proceed with assessments and intervention plans. Ideal assessment approaches. Twenty-five percent of the responses under the theme Reasons Interdisciplinary Collaboration Is Important were coded as the subtheme Ideal Assessment Approaches. Improving assessment practices and gaining more knowledge about the student and his or her disability was the foundation for this theme. Within this theme, four codes emerged: Benefits Evaluation Process, Helpful Process, Making Informed Decisions, and Understanding Impact of Disability. Benefits Evaluation Process discussed how having more professionals collaborating creates a more fair, accurate, and comprehensive evaluation. “I think it is helpful to get more information from other specialists regarding the best way to assess students in order to make sure the assessment is fair and accurately assesses the student’s ability” is an example of a response for this code. The code Helpful Process addressed the feeling that having more minds working on a case could only be an advantage. Making Informed Decisions was about how planning and other choices were subjectively improved by having the input of multiple professionals rather than just one. Understanding Impact of Disability reviewed the fact that getting information from other disciplines allows a professional to understand how a disability, such as HL, affects not only his or her assessment procedures but also how the disability may impact the day-today life of the student. The following response is an example of this code: “I feel it is very helpful to collaborate with other professionals about certain students to fully understand the child and what that child can and cannot do because of his disabilities.”
Language, Speech, and Hearing Services in Schools • 1–13
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Primary Theme 2: Barriers to collaboration. In addition to providing reasons why interdisciplinary collaboration is important, some respondents also elaborated on what barriers prevent collaboration in their workplace. There are three subthemes under this primary theme as well: (a) Lack of Time, (b) Lack of Availability, and (c) Interpersonal Complications. Lack of time. Fifty percent of the responses under the theme Barriers to Collaboration were coded as the subtheme Lack of Time. Lack of Time as a subtheme encompasses the fact there are not enough hours in the day for professionals to accomplish their daily tasks and collaborate effectively with others. Two codes emerged in this subtheme: Not Enough Hours and Heavy Workload. The code Not Enough Hours explained that professionals do not collaborate as much as they wish to due to lack of time in the school day. Some responses talked about the school system not allowing enough time for proper collaboration, so oftentimes any collaboration that is accomplished is not adequate. Heavy Workload was the other time-consuming issue that prevented collaboration. Lack of availability. Twenty-seven percent of the responses under the theme Barriers to Collaboration were coded as the subtheme Lack of Availability. This subtheme described collaboration not being attainable for a variety of reasons. Two codes emerged in this subtheme: Collaboration Unavailable and Professional Not Available. Collaboration Unavailable as a code was applied to only one response; the respondent expressed that, although collaboration is ideal, it is not available in every circumstance. It is unclear whether the respondent meant that their school does not prioritize collaboration or if there are factors preventing collaboration from happening. Professional Not Available described the belief that professionals are unable to collaborate to the fullest extent because all necessary providers (e.g., audiologists) are not readily available in their school. Interpersonal complications. Twenty-three percent of the responses under the theme Barriers to Collaboration were coded as the subtheme Interpersonal Complications. This theme addresses the more humanistic side of collaboration, where each individual has personal reasons as to why they do or do not collaborate with others. Three codes emerged in this subtheme: Discipline Not Valued, Does Not Want To, and Unsure of Process. Discipline Not Valued was only mentioned in one response. The respondent expressed that, although they wished to collaborate with audiologists more when it comes to assessing children with HL, the Deaf community in their area does not value the input of audiologists, which can make it harder to bring an audiologist onto the interdisciplinary team for a Deaf child. The code Does Not Want To expressed either the feeling that it was not up to them to coordinate collaboration or that those around them had a similar mentality. The final code, Unsure of Process, is intended to portray the desire to collaborate more but that some professionals are uncertain of what the process of collaboration is for their place of employment.
Research Question 3: Additional Training Desired Research Question 3a Participants were queried about the amount of HL-related education and experience they received in various settings. The possible answers ranged from “none” to “entire focus.” Most participants, both SPs and SLPs, reported that HL was either a minor focus of their training in various settings or that they received no training on HL in a particular setting. During graduate school, 86% of SLPs and 59% of SPs reported that HL was a minor focus of their coursework, and 5% of SLPs and 35% of SPs reported that they received no training on HL during graduate school. In their externship opportunities, only 70% of SLPs and 31% of SPs had HL as at least a minor focus of their training. Table 6 shows the amount of previous training participants received in five different settings. Research Question 3b The questions in this section also asked how much HL training the participants wished they had received relative to the amount of training they did receive. Responses ranged from “a lot less” to “a lot more.” For SLPs, 96% of participants indicated that they desired the same amount of training or more training in graduate school, and 76% reported that they wished they had gotten more training during their externship. For SPs, 96% of participants indicated that they desired the same amount of training or more training in graduate school, and 82% reported that they wished they had gotten more training during their externship. Very few participants reported that they wished they received less training on HL in their graduate coursework (SLP: 3%, SP: 3%) or during their externship (SLP: 2%, SP: 3%). See Table 7 for complete description of responses. For future training opportunities related to HL, 51% of participants reported that they would be open to receiving training at an in-person conference, 63% reported that an in-service training in their school would be beneficial, and 75% reported that online training would be a desirable way to get more education about HL.
Discussion Research Question 1: Experience and Confidence in Assessing Students With HL and Other Disabilities Participants expressed a range of confidence scores in skill set types related to assessing and treating students who have HL and other co-occurring disabilities. For the more general category of the participants’ confidence in their ability to assess a child with HL and other disabilities, the range was quite broad, but the average confidence level selected was around the halfway point on the 0–100 scale. A similar distribution was found for the participants’ reports of their ability to determine whether academic and developmental issues were due to HL or due to concerns associated with another disability. These results are likely to be related to that fact that the SLPs and SPs are able to draw
Muncy et al.: Confidence Hearing Loss Co-Occurring Disabilities
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
9
Table 6. Percentage of selections in each category in response to the question: “Please indicate your practical and clinical experiences related to hearing loss.” Amount of experience Setting Graduate coursework SLP SP Professional development SLP SP Externship opportunities SLP SP Internship opportunities SLP SP Employment opportunities SLP SP
None
Minor focus
Major focus
Entire focus
Not applicable
5 35
86 59
9 4
0 1
0 1
20 34
71 61
8 4
1 1
0 0
28 65
61 29
8 2
1 0
2 4
31 61
61 32
5 3
1 1
2 3
29 50
60 43
8 3
1 2
2 2
Note. Data are in percent. SLP = speech-language pathologist; SP = school psychologist.
on their knowledge of their own fields to complete an accurate assessment. When the tasks presented related more singularly to HL, the professionals reported significantly less confidence in their abilities. As can be seen from Table 2, both SLPs and SPs exhibited lower confidence scores when it came to their ability to determine the functional status of a hearing aid, and the scores were even lower for the topic of being able to troubleshoot a malfunctioning hearing aid. This limited confidence working with hearing aids is consistent with reports from Richburg and Knickelbein (2011), where 61% of SLPs rated themselves as not well prepared to help students when a hearing aid begins to malfunction and
only 55% reported conducting hearing aid checks. This is an area of concern, as these are tasks that should be performed by every professional with which a student with HL interacts (34 C.F.R. § 300.113, 2012). If the child’s hearing aid is not functional, then the student may not effectively hear instructions in a therapy session and thus will receive limited benefit from the session, or assessment results may be skewed due to a malfunctioning hearing aid. As can be seen from Figure 2, SLPs expressed more confidence in their abilities than SPs in the more general skill set types and the HL-specific skill set types. This difference in scores is likely due to the fact that SLPs receive more HL-related education in their degree path than SPs
Table 7. Percentage of selections for each category in response to the question: “Relative to the amount of training you had concerning the assessment of children with hearing loss and other co-occurring disabilities, how much more or less training would you have preferred in each of these environments?” Amount of training desired Setting Undergraduate coursework SLP SP Graduate coursework SLP SP Externship opportunities SLP SP Internship opportunities SLP SP Research opportunities SLP SP
A lot less
A little less
Same
A little more
A lot more
Not applicable
1 3
2 1
39 48
42 29
7 4
9 15
1 2
2 1
15 7
45 57
36 32
1 1
1 3
1 0
19 12
50 61
26 21
3 3
1 3
1 1
23 13
49 54
25 25
1 4
2 4
2 1
40 42
33 27
5 14
18 12
Note. Data are in percent. SLP = speech-language pathologist; SP = school psychologist.
10
Language, Speech, and Hearing Services in Schools • 1–13
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
receive. Although neither discipline makes HL the main focus of the field, knowing how to appropriately interact with this population, including being comfortable with skills such as ensuring a hearing aid is working, is important nonetheless. It was found that the number of students with HL that the professional had worked with did predict their confidence in being able to perform an appropriate assessment for the student and their confidence in evaluating the etiology of an academic or social complication the student may be facing. However, the differences were not significant for every comparison. Although working with more students with HL did predict an increase in confidence, it was only up to a limit of 10–20 students. If the professional had worked with more than 20 students with HL, there was not a significant change in confidence level. A similar plateau effect was found for the amount of HL-related training received in graduate school. Although receiving more training did predict an increase in confidence, there was not a significant difference between having HL as a minor focus and having it as a major focus of the educational program. These results indicate that it is important for every professional to have some exposure to many different disciplines. It is not, and should not be, an expectation for every professional to be an expert in every field. Results indicate that, if professionals gain at least some experience working with the population of students with HL, then their confidence is predicted to increase. A higher confidence level can help the professional to deliver a better quality of service. Furthermore, gaining hands-on experience, in addition to theoretical knowledge, can only benefit a professional when he or she is faced with a patient who has comorbid disorders that fall outside the professional’s normal range of focus. In addition, participants from both professions reported working with a similar number of students with HL, so professionals from both of these fields should know how they will be expected to deliver services for this population.
evaluations for these students. This may be due to factors revealed in the qualitative analysis, such as respondents feel blocked by factors such as not having a certain professional available for collaboration or they do not have enough hours in the day to collaborate to the extent they wish. Many SP respondents talked about how they relied on SLPs for information about the hearing status of the student. This is unfortunate, because it should be the responsibility of the educational audiologist, not the SLP, to cover hearingrelated services. Some of the hearing services they are expected to provide may also be outside their scope of practice. However, because of a lack of audiologists employed in the school system (DeConde Johnson & Seaton, 2011), SLPs are often the only professional in the school who has any training related to HL and were even referred to by Brackett (1997) as the “expert” on HL in many schools. This is perhaps connected to the selection of the option of “limited access to other professionals” as a common barrier to collaboration (selected by 32% of respondents). Professionals in the schools may not have access to the professionals they would turn to first and are thus turning to a colleague who has at least some training in the field of necessity. Participants noted that limited time was the biggest barrier to interdisciplinary collaboration, which is consistent with Mostert’s report from over 20 years ago that time is a major limitation on the amount of collaboration that is accomplished in schools (Mostert, 1996). It is unfortunate that so many professionals still cannot collaborate to the extent they desire simply due to lack of hours in the school day. More collaboration allows for better transmission of information and can create a better overall intervention plan for a student with disabilities. It should be a focus of school administrations in the future to allow more time in the workday for collaboration, as this can improve the degree of care their professionals are able to provide for students with disabilities.
Research Question 2: Attitudes About Interdisciplinary Collaboration
Most participants reported that they would have preferred to receive either a little or a lot more training about HL during their education and internships/externships. Educational programs and externship sites should ensure that they are providing future professionals with appropriate exposure to students with HL and other co-occurring disabilities. As indicated by the current results, appropriate exposure can build the confidence of these future professionals and increase the quality of services they provide later in their careers. When asked how they would best like to receive this training, the choices were varied between online, in-services, and at conferences. This indicates that these professionals have a desire to learn more information and are open to various ways in which it may be presented to them. School districts and professional organizations should be aware of this and should work to arrange trainings for these professionals so that students with HL and other co-occurring disabilities are better served. A future study designed specifically to determine the most effective means
Nearly all of the participants reported that they feel interdisciplinary collaboration is important when working with students who have HL and other co-occurring disabilities, as evidenced by their responses to the open-ended question on this topic. One of the most common responses was that each member of the collaboration team has his or her own knowledge and perspectives, which can bring more understanding about the overall functioning of the child. Although there were many different reasons given as to why interdisciplinary collaboration is important, the common view that it does hold high value relayed the idea that the students and the professionals truly benefit from the process. School-based SLPs and SPs want to engage in practices that are helpful for them and the students they serve, but 68% of SLPs and 55% of SPs reported that they do not “almost always” collaborate with other professionals during
Research Question 3: Additional Training Desired
Muncy et al.: Confidence Hearing Loss Co-Occurring Disabilities
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
11
for better preparing SLPs and SPs for interacting with this population of children with HL and other co-occurring disabilities is warranted.
Limitations of the Current Study The current study was limited by several factors. Educational audiologists were not included as participants, so therefore, their insights and opinions were not examined. As educational audiologists should be the primary professionals responsible for this population, their insights are particularly relevant. In addition, this was not a direct observational study, so the results of the current study are based solely on self-report of confidence levels. The current study did not examine the actual abilities of SLPs and SPs to properly perform various skills, such as troubleshooting a hearing aid.
Conclusions Overall, the results of the current study indicate that school-based SLPs and SPs have not received sufficient training or experience in the area of working with children who have HL and other co-occurring disabilities. This has the potential to affect the quality of services they are providing to these children and thus needs to be addressed within the school system and the fields of school psychology and speech-language pathology. Participants reported low confidence across several skill set types that are necessary for proper assessment and treatment of students with HL and other co-occurring disabilities and that they desired more training on HL than they received. Interdisciplinary collaboration was noted by participants to be an important practice that allows professionals to better understand their students and to provide the students with the best opportunities for success. However, many participants noted that there are barriers preventing collaboration with the professionals who do have knowledge about HL. Although an ideal solution would be to hire sufficient numbers of educational audiologists, these results indicate that, at a minimum, more training needs to occur for the other professionals who work on the front line with students who have HL as one of their multiple disabilities.
Acknowledgments We gratefully acknowledge the study design and data analysis contributions of Karen Filimoehala, Shea Long, and Nicole Thiede.
References Bess, F. H., Dodd-Murphy, J., & Parker, R. A. (1998). Children with minimal sensorineural hearing loss: Prevalence, educational performance, and functional status. Ear and Hearing, 19(5), 339–354. Biddle, B. M. (2014). Educator-perceived affects of autism spectrum disorder on deaf children: A national survey study. EKU
12
Libraries Research Award for Undergraduates, 18. Retrieved from http://encompass.eku.edu/ugra/2014/2014/18 Brackett, D. (1997). Intervention for children with hearing impairment in general education settings. Language, Speech, and Hearing Services in Schools, 28(4), 355–361. https://doi.org/ 10.1044/0161-1461.2804.355 Braden, J. P. (1992). Intellectual assessment of deaf and hard-ofhearing people: A quantitative and qualitative research synthesis. School Psychology Review, 21(1), 82–94. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa Briscoe, J., Bishop, D. V. M., & Norbury, C. F. (2001). Phonological processing, language, and literacy: A comparison of children with mild-to-moderate sensorineural hearing loss and those with specific language impairment. Journal of Child Psychology and Psychiatry and Allied Disciplines, 42(3), 329–340. https://doi.org/10.1017/S0021963001007041 Buskermolen, W. M., Hoekman, J., & Aldenkamp, A. P. (2012). Risk factors leading to behavioural problems in individuals with hearing impairments and intellectual disabilities. International Journal on Mental Health and Deafness, 2(1), 33–45. Cappelli, M., Daniels, T., Durieux-Smith, A., McGrath, P. J., & Neuss, D. (1995). Social development of children with hearing impairments who are integrated into general education classrooms. The Volta Review, 97(3), 197–208. Culbertson, J. L., & Gilbert, L. E. (1986). Children with unilateral sensorineural hearing loss: Cognitive, academic, and social development. Ear and Hearing, 7(1), 38–42. DeConde Johnson, C., & Seaton, J. (2011). Educational audiology handbook (2nd ed.). Independence, KY: Delmar Learning. Dedoose Version 7.0.23, web application for managing, analyzing, and presenting qualitative and mixed method research data. (2017). Los Angeles, CA: SocioCultural Research Consultants. Retrieved from http://www.dedoose.com Easterbrooks, S. R., Lederberg, A. R., Miller, E. M., Bergeron, J. P., & Connor, C. M. (2008). Emergent literacy skills during early childhood in children with hearing loss: Strengths and weaknesses. The Volta Review, 108(2), 91–114. Retrieved from http://eric.ed.gov/?id=EJ837076 Gallaudet Research Institute. (2010). Regional and national summary report of data from the 2009–2010 annual survey of deaf and hard of hearing children and youth. Washington, DC: GRI, Gallaudet University. Harrington, M., DesJardin, J. L., & Shea, L. C. (2010). Relationships between early child factors and school readiness skills in young children with hearing loss. Communication Disorders Quarterly, 32(1), 50–62. https://doi.org/10.1177/ 1525740109348790 Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. Harrison, M., Page, T. A., Oleson, J., Spratford, M., Berry, L. U., Peterson, B., . . . Moeller, M. P. (2016). Factors affecting early services for children who are hard of hearing. Language, Speech, and Hearing Services in Schools, 47(1), 16–30. Hogan, A., Shipley, M., Strazdins, L., Purcell, A., & Baker, E. (2011). Communication and behavioural disorders among children with hearing loss increases risk of mental health disorders. Australian and New Zealand Journal of Public Health, 35(4), 377–383. https://doi.org/10.1111/j.1753-6405. 2011.00744.x
Language, Speech, and Hearing Services in Schools • 1–13
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Indiana Center for Deaf and Hard of Hearing Education. (2013). Guidelines for the assessment and educational evaluation of deaf and hard-of-hearing children in Indiana. Based on 511 IAC Article 7, 2008, 1–38. Luckner, J. L., & Bowen, S. (2006). Assessment practices of professionals serving students who are deaf or hard of hearing: An initial investigation. American Annals of the Deaf, 151(4), 410–417. https://doi.org/10.1353/aad.2006.0046 Mostert, M. P. (1996). Interprofessional collaboration in schools: Benefits and barriers in practice. Preventing School Failure, 40(3), 135–138. https://doi.org/10.1080/1045988X.1996.9944667 National Association of School Psychologists. (2017). Who are school psychologists. Retrieved from https://www.nasponline. org/about-school-psychology/who-are-school-psychologists O’Connell, J., & Casale, K. (2002). Attention deficits and hearing loss: Meeting the challenge. The Volta Review, 104(4), 257–271. Page, T. A., Harrison, M., Moeller, M. P., Oleson, J., Arenas, R. M., & Spratford, M. (2018). Service provision for children who are hard of hearing at preschool and elementary ages. Language, Speech, and Hearing Services in Schools, 49, 965–981. https://doi.org/10.1044/2018_LSHSS-17-0145 Richburg, C. M., & Knickelbein, B. A. (2011). Educational audiologists: Their access, benefit, and collaborative assistance to
speech-language pathologists in schools. Language, Speech, and Hearing Services in Schools, 42(4), 444–460. https://doi.org/ 10.1044/0161-1461(2011/10-0011) Roush, J., & Wilson, K. (2013). Interdisciplinary assessment of children with hearing loss and multiple disabilities. SIG 9 Perspectives on Hearing and Hearing Disorders in Childhood, 23(1), 13–26. https://doi.org/10.1044/hhdc23.1.13 Routine checking of hearing aids and external components of surgically implanted medical devices, 34 C.F.R. § 300.113 (2012) Schum, R. (2003). Psychological assessment of children with multiple handicaps who have hearing loss. The Volta Review, 104(4), 237–255. Van Eldik, T. (2005). Mental health problems of Dutch youth with hearing loss as shown on the youth self report. American Annals of the Deaf, 150(1), 11–16. Vernon, M., & Rhodes, A. (2009). Deafness and autistic spectrum disorders. American Annals of the Deaf, 154(1), 5–14. Wake, M., Hughes, E. K., Poulakis, Z., Collins, C., & Rickards, F. W. (2004). Outcomes of children with mild–profound congenital hearing loss at 7 to 8 years: A population study. Ear and Hearing, 25(1), 1–8. https://doi.org/10.1097/01.AUD.0000111262. 12219.2F
Muncy et al.: Confidence Hearing Loss Co-Occurring Disabilities
Downloaded from: https://pubs.asha.org Sarah Leopold on 12/08/2019, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
13
