20 When Deaf and Hard of Hearing Students Have Autism

Suggestions for Connection

By Vladimir Kogan

Vladimir Kogan is a father of an autistic child, avid autism advocate, and founder and CEO of Autism treatment center in Las Vegas. If you want to reach out to him, contact Nevada Autism Center, 7730 West Sahara Avenue #115, Las Vegas, NV 89117, (702) 660-2005, https://nevadaautism.com

Deaf or Hard of Hearing children can face challenges in communication and social interaction as they interact, sometimes exclusively, with a community that does usually does not know sign language. For some of these children, these challenges are compounded by an additional factor: Autism Spectrum Disorder (ASD). ASD is a common neurodevelopmental condition affecting up to one in 38 children aged 8 to 11 years (Maenner et al., 2023). The prevalence of autism in deaf children is not well-defined and remains a topic of uncertainty (McFayden et al., 2023). Hearing differences often coincide with autism, with the prevalence of ASD being higher among deaf and hard-of-hearing (D/HH) children, ranging from 7% to 9%, compared to approximately 1.7% to 2% in the general population (McFayden et al., 2023).

There is not a lot of additional scientific evidence to describe current, accurate prevalence rates of children who are D/HH and have an autism diagnosis. An international review conducted by Beers et al. in 2014 found that around 3.5% of children diagnosed with autism are also deaf or hard of hearing. A specific study from a single hospital in Sweden suggested that the prevalence of autism is higher among deaf children compared to their hearing peers (Rosenhall et al., 1999). Unfortunately, these findings are based on older studies, and updated research is necessary to gain a more accurate understanding of these prevalence rates.

D/HH children who are autistic are also identified later than other children (MacFayden, 2023). While most children are diagnosed with autism at three years old, deaf and hard of hearing children are diagnosed at 5.5 to 6 years old (Szarkowski et al., 2014). As so much linguistic and social development occurs during those early years, that 3-year difference in diagnosis may be especially significant. Just as significantly, 72% of the children who were belatedly diagnosed had been previously misdiagnosed, either with another condition or by having their ASD symptoms attributed to their hearing loss.

Several reasons exist for this late diagnosis (McFayden, 2023):

• An overlap in behaviors—Behaviors resulting from sensory loss and communication sometimes mask those resulting from autism, as providers attribute the child’s behavior to hearing loss alone (McFayden, 2023).
• The similarity in underlying causes—Researchers have cited premature birth (cited in McFayden, 2013) and congenital cytomegalovirus, among other causes of both ASD and hearing loss.
• A lack of diagnostic tools— Existing assessment measures for this complex condition often fail to account for the intersection of communication needs, sensory sensitivities, and any cognitive disfunction.
• A lack of expertise—While there are individuals who are experts in hearing loss and deafness and individuals who are experts in autism, rarely are there individuals with expertise in both (Szarkowski, et al., 2014).

Seeing the World Differently

Deaf and hard-of-hearing children who have autism experience the world differently from other children. Their reactions to everyday stimuli can be unique and sometimes unexpected. For example, one of my students at a public school, a young 7-year-old girl, E., became fascinated with light patterns through leaves at recess. She would spend long periods observing how sunlight filtered through the trees, entranced by the changing patterns and shadows. This kind of complex sensory processing, implicit in autism, requires parents and educators to develop a nuanced approach to communication and interaction.

Another student, L., who had many high needs, demonstrated an intense focus on his daily routines. Being both HH and autistic, L. was a 10-year-old student of mine who relied heavily on visual schedules to navigate his day. Any unexpected changes led to significant anxiety and meltdowns. During school assemblies, when the routine was disrupted, L. would become highly distressed because he couldn’t hear the announcements clearly, and his visual schedule didn’t account for the change in his day.

Another student in an ABA clinic program, M., who was 11 and preferred remaining isolated from others, had difficulty interpreting social cues. For example, during a game where one child began to playfully tease another, M. tended to perceive the teasing as hostile or unfriendly because they couldn’t hear the playful tone or see the accompanying smile that indicated the teasing was in good fun. As a result, M. would sometimes react defensively or angrily, believing she was being genuinely bullied. Her reliance on visual cues alone was insufficient, demonstrating the need for explicit social skills training adapted to her communication style.

My experiences with these children taught me the importance of tuning into their individual sensory experiences. Practical applications of this principle involve developing strategies and modifying the environment that accommodates their sensory preferences, degree of hearing loss, and communication needs. That way, we can ensure they feel heard and valued while strengthening their language development.

Teachers know the importance of tuning into students’ sensory experiences. They apply strategies to modify the environment to accommodate their students’ sensory and communication needs. They never lose track of the importance of fostering language development.

The following strategies may help in the classroom:

Dual-Linguistic & Multimodal Strategies

Using American Sign Language (ASL) alongside written and audio English can create a language-rich environment (Sparharm, 2023). Exposing students to both ASL and English allows them to better understand and express themselves through multiple linguistic modalities. Caregivers and educators can connect the deaf and hearing worlds while also meeting the linguistic and developmental needs of D/HH children with ASD.

For example, consider a previous student of mine, S., a sweet 9-year-old deaf girl with ASD. Her teachers implemented a dual visual linguistic approach, where all instructions and lessons were presented simultaneously in ASL and written English.

To achieve this, the classroom utilized both a live ASL interpreter and written materials. During lessons, the interpreter would sign the teacher’s spoken words in ASL, while written instructions and lesson content were displayed on a screen or whiteboard in English. This allowed S. to access the information in her preferred visual mode, either through ASL or by reading the English text. During story time, the teacher used an ASL interpreter (either in-person or via a YouTube video) to sign the story while displaying the English text and corresponding pictures on a screen. This approach enabled S. to follow along with the story visually in ASL while also seeing the English text, aiding her literacy development.

For classroom instructions, the teacher provided written instructions on the board or screen while the ASL interpreter signed the same instructions. This ensured S. could focus on either the ASL interpretation or the written English, depending on her comfort and comprehension level now. Interactive lessons, such as science experiments or group activities, involved the interpreter signing the instructions first, followed by showing them in written form. This dual presentation reinforced the instructions and ensured S. could understand and participate fully.

By alternating between focusing on the ASL interpreter and the written English text, S. engaged with the material in a way that accommodated her learning needs and preferences. This dual approach not only supported her understanding but also helped bridge her ASL and English language skills.

Another case is M., a bright and inquisitive 11-year-old boy who was HH and highly splintered needs. His teachers used a combination of spoken English (with visual supports), written English, and ASL to teach science concepts. When learning about the water cycle, Alex saw the process illustrated in a diagram with English labels, watched an ASL video explanation, and participated in a hands-on experiment describing each step in spoken English and ASL. A multi-modal approach catered to Alex’s visual learning style and helped him understand complex concepts more thoroughly.

Create Visually Friendly Environments

Teachers can mitigate students’ sense of isolation by designing classrooms where students receive individualized instruction and social interventions designed to foster friendships and increase participation in group activities.  In a local public school, I mentored a shy 7-year-old boy, D., who was deaf with ASD and struggled to connect with his classmates. His teachers implemented a buddy system, pairing D. with a classmate who knew sign language because the helping classmate had an older sister was also HH. This helped D. feel more included and encouraged other students to learn basic signs.

A sensory-friendly room was set up at a community center near this school at an after-school program where children like the young man in my previous example could take breaks during after-school care. This space included visual schedules, quiet zones, and sensory toys. Now that he had a place to decompress whenever needed, he was much more prepared to join in on recreational group activities. Children can highly benefit from targeted supports and friendly, inclusive environments that encourage social engagement and relationship development.

Visual and Technology-Based Supports

In addition to using ASL, students struggling with conventional communication methods can benefit from augmentative and alternative communication systems, such as picture-based communication systems, sign language, gesture-based communication, and high-tech AAC devices.

Further programs like Picture Exchange Communication Systems, speech-generating devices (SGDs), and tablet-based AAC apps like Proloquo2Go or TouchChat can benefit Personalized tools, such as customized communication boards, social stories with visual supports, and video modeling, create a responsive, language-rich environment. These findings emphasize the need to integrate advanced visual and technology-based aids to expand the communicative options for these children.

Expressive Therapies and Creative Arts

Expressive therapies offer creative avenues for language use and social interaction. These therapies include music, art, dance/movement, drama, pet and equine-assisted activities, all designed to facilitate communication and emotional expression.

For instance, music therapy might use rhythm exercises with percussion instruments, while art therapy could involve collaborative painting projects. Dance and drama therapies incorporate movement and role-playing to enhance body awareness and social skills. These multisensory experiences cater to visual and tactile learning preferences, providing alternative means of communication beyond traditional language.

Another category of therapy—equestrian or animal therapy—involves students interacting with and caring for horses or other animals. Working with animals helps students develop empathy, which also gives them the opportunity to communicate and explore in ways that complement their language comprehension and interpersonal skills.

Salvador and Pasiali (2016) discuss the significance of incorporating expressive therapies and community involvement for D/HH children with ASD. Their study highlights how creative approaches, such as music and art therapy, can facilitate emotional expression and social interaction for these children. They found that integrating these therapies into educational programs helps in developing communication skills and emotional resilience by providing alternative ways for children to express themselves and connect with others.

Community Participation

Incorporating community experiences into the lives of deaf and hard-of-hearing children can encourage independence and cultivate a sense of inclusion (Scherer et al., 2023). Structured activities in inclusive settings allow these children to thrive by enhancing their social skills, reducing feelings of isolation, and improving overall well-being (Scherer et al., 2023). Such activities as swimming lessons, playgroups, and educational programs offer deaf and hard-of-hearing autistic children opportunities to interact with peers and develop fundamental social skills and can promote a sense of well-being (Days, 2023).

Additionally, involvement in community programs fosters a sense of belonging by building supportive networks for both children and parents. Playgroups and early childhood development programs enable children to interact with others who share similar experiences, while parents benefit from shared knowledge and support from other families (Scherer et al., 2023). Sensory-friendly museums or art galleries allow students to engage with interactive exhibits and connect with their environment. Participating in adaptive sports programs promotes physical activity and teamwork. Community gardening teaches children about nature and cooperation while volunteering at animal shelters helps them develop empathy and a sense of responsibility.

Deaf-friendly movie screenings or theater performances with captioning or sign language interpretation also provide real-world contexts for applying social skills and foster a sense of belonging within the broader community.

Deaf and hard-of-hearing children who are autistic often find themselves in a unique position of isolation, struggling to form connections with those around them. Though autism is more prevalent in the D/HH population than in the general population and overlooked in the child’s early years, teachers, parents, and professionals can effectively structure environments and interactions so that these children are less isolated and alone. Every breakthrough, every new connection forged, reminds us of the power of human connection and the importance of our work in creating a more inclusive world for all children.

References:

Beers, A. N., McBoyle, M., Kakande, E., Dar Santos, R. C., & Kozak, F. K. (2014). Autism and peripheral hearing loss: a systematic review. International journal of pediatric otorhinolaryngology, 78(1), 96–101. https://doi.org/10.1016/j.ijporl.2013.10.063

Days, L. (2023). Diving into inclusion: The importance of swimming lessons for deaf and hard of hearing children. Deaf Children Australia. Retrieved July 9, 2024, from https://www.deafchildrenaustralia.org.au/diving-into-inclusion-the-importance-of-swimming-lessons-for-deaf-and-hard-of-hearing-children/

Maenner MJ, Warren Z, Williams AR, et al. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2020. MMWR Surveill Summ 2023;72(No. SS-2):1–14. DOI: http://dx.doi.org/10.15585/mmwr.ss7202a1.

McFayden, T. C., Culbertson, S., DeRamus, M., Kramer, C., Roush, J., & Mankowski, J. (2023). Assessing Autism in Deaf/Hard-of-Hearing Youths: Interdisciplinary Teams, COVID Considerations, and Future Directions. Perspectives on psychological science: a journal of the Association for Psychological Science, 18(6), 1492–1507. https://doi.org/10.1177/17456916231178711

Nevada Autism Center. Sensory Issues and Autism. https://nevadaautism.com/sensory-issues-and-autism/

Nelson, C.& Bruce, S.M. (2019). Children Who Are Deaf/Hard of Hearing with Disabilities: Paths to Language and Literacy. Educ. Sci., pp. 9, 134. https://doi.org/10.3390/educsci9020134

Rosenhall, U., Nordin, V., Sandström, M., Ahlsén, G., & Gillberg, C. (1999). Autism and hearing loss. Journal of autism and developmental disorders, 29(5), 349–357. https://doi.org/10.1023/a:1023022709710

Salvador, K., & Pasiali, V. (2016). Intersections between music education and music therapy: Education reform, arts education, exceptionality, and policy at the local level. Arts Education Policy Review, 118(2), 93–103. https://doi.org/10.1080/10632913.2015.1060553

Scherer, N., Smythe, T., Hussein, R., Wapling, L., & Hameed, S., et al. (2023). Communication, inclusion and psychological wellbeing among deaf and hard of hearing children: A qualitative study in the Gaza Strip. PLOS Global Public Health, 3(6), e0001635. https://doi.org/10.1371/journal.pgph.0001635

Shield, A., Graham, P., & Neild, R. (2023). Educational Strategies for Deaf Children with Autism Spectrum Disorder (ASD), Perspectives on Early Childhood Psychology and Education, 5(2), Article 7. https://doi.org/10.58948/2834-8257.1062

Sparham, H. (2023). Student-teacher and teacher perceptions on the use of visual strategies to support academic language in different groups of learners (BA [Hons] Primary Education Studies). York St John University, School of Education, Language and Psychology.

Szarkowski, A., Mood, D., Shield, A., Wiley, S., & 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(4), 241–259. https://doi.org/10.1055/s-0034-1389097