September 22, 2009 Feature

Serving Students with Hearing Loss in the Schools

Speech and Language Services for Students in the Mainstream

The number of infants receiving cochlear implants (CIs) is increasing, and many of these children later enter mainstream classrooms from the beginning of their formal education. Early mainstreaming of these children is a byproduct of the technology that has become more prevalent as performance with the device has improved (Geers& Brenner, 2003; Francis, Koch, Wyatt, &Niparko, 1999; Nevins & Chute, 1995).

Many infants who are deaf are now receiving a cochlear implant at 12 months of age, and they frequently—but not always—achieve a level of language competence that allows them to be educated with their peers. The relationship of a child's language age to chronological age affects the child's learning across all areas of the curriculum (Spencer, Barker, & Tomblin, 2003) and should be considered in decisions about educational placement and delivery of services by audiologists and speech-language pathologists. To provide the best possible educational outcomes for children with hearing loss, collaboration is needed among speech and hearing professionals (educational audiologists, teachers of deaf children) and between them and general education classroom teachers.

Placement and Support Services

When language age and chronological age are similar for a child with hearing loss, placement in local school districts may yield the best educational outcomes (Nicholas &Geers, 2006). Yet a child with the linguistic ability to keep pace with the academic demands of the classroom may still encounter some pitfalls. Speech and hearing professionals must continue to monitor and maintain vigilance to ensure that the child has continuous access to information. In this situation, the professionals' primary roles may be to enhance the child's capabilities to maintain commensurate status in the classroom.

In some instances, a child with a CI may demonstrate a chronological age and language age that are closely aligned but not equivalent. The child may enjoy early classroom success but later falter as the curriculum content becomes more challenging. Evaluation of this at-risk child can ensure that the child is identified and provided with appropriate support services to keep him or her on par linguistically with peers.

Although the SLP and audiologist may provide support to this student, they may need to sound the alarm should linguistic/academic performance begin to decline. School districts may be inclined to wait for a scheduled triennial evaluation; the responsible speech and hearing professional, however, may wish to advocate for earlier assessment.

Replacement Services

A child with a CI will have greater challenges in the mainstream if there is a marked disparity between chronological and language age. In this situation, inadequate options for service delivery may result in educational placements that are less than optimal for continued language and academic growth. This situation may be true especially in sparsely populated areas that lack professionals to provide a continuum of educational placements. Under these circumstances, the speech and hearing professional may find it necessary to replace classroom instruction with individual intervention sessions. Close collaboration with the classroom teacher ensures that the most salient information is used to design intervention activities. If the speech and hearing professional provides parallel and decontextualized services, a child may experience little true learning in the mainstream classroom environment.

Thus, placement of a young child in a mainstream classroom may not result in the best educational outcomes. The decision to mainstream very young children is based on basic auditory, speech, and language skills that may be age-appropriate for a toddler but may not reflect future capabilities. In addition, parents' desire to educate their child in the local school district may cloud the issue of preparedness and create potential barriers to success. Unfortunately, premature placement in mainstream classrooms may have residual effects on a child's self-esteem if communication and classroom status are compromised by less-than-adequate language competence.

Measures that assess aspects of classroom performance to determine a child's readiness for mainstream education and his or her ability to sustain academic performance in the mainstream will assist in making this important decision.

Many educational tools assess classroom performance of children with hearing loss, including the Screening Identification for Targeting Educational Risk (SIFTER; Anderson, 1989), Listening Inventories for Education (LIFE; Anderson & Smaldino, 1998), and Assessment of Mainstream Progress (AMP; Chute & Nevins, 2006). The AMP was developed in response to the early mainstreaming of children with CIs; it determines a child's readiness for mainstream placement and monitors mainstream progress.

Success Factors for Mainstream Placement

Parents, teachers, school administrators, and school districts also play a role in supporting a child's success in the mainstream. Parents of a successfully mainstreamed child acknowledge the child's strengths and challenges, have realistic expectations for classroom performance, cooperate with teachers and support personnel, and recognize the boundaries of regular education classrooms. Most importantly, these parents support school work at home (Teller & Lindsey, 1987).

Teachers who approach a child with a CI with unconditional acceptance in the classroom create a social/emotional environment in which the child can be successful. These teachers are willing to make instructional changes as needed and to obtain knowledge and skills related to hearing loss and CIs.

Principals who are enthusiastic and committed to making mainstream education work for the child with a CI are crucial. By providing opportunities for staff to learn about CIs and allocating funds for acoustic and educational accommodations, administrators control the organization's response to educating a child with a CI. Mainstreaming a child with a CI will be successful only with financial support at the school district level for all services the child requires (Chute & Nevins, 2006).

SLPs and audiologists in schools have a greater likelihood of encountering a child with a CI than ever before. Delivering appropriate services to these children requires a program tailored to meet the child's profile. The relationship between a child's chronological and language age and its impact on placement in the mainstream may provide the crucial information necessary to develop an effective intervention plan. Vigilant professionals who monitor the linguistic and academic demands of the classroom and the child's ability to meet those demands will be better able to address the challenges of mainstream placement for every child with a CI.

Patricia M. Chute, EdD, CCC-A, is a professor and dean of the School of Health and Natural Sciences at Mercy College in Dobbs Ferry, N.Y. She is the former director of the Cochlear Implant Center at Lenox Hill Hospital and Manhattan Eye, Ear and Throat Hospital and has been involved with cochlear implants since 1979. Contact her at

Mary Ellen Nevins, EdD, is a teacher of children who are deaf and hard of hearing. She is the national director of Professional Preparation in Cochlear Implants, a continuing education program designed for speech and hearing professionals.

cite as: Chute, P. M.  & Nevins, M. (2009, September 22). Serving Students with Hearing Loss in the Schools : Speech and Language Services for Students in the Mainstream. The ASHA Leader.

Assessing the Academic Progress of Students with Hearing Loss

The Assessment of Mainstream Progress (AMP; Chute & Nevins, 2006) was developed specifically in response to the early mainstreaming of children with cochlear implants to determine a child's readiness for and progress in mainstream placement.

The rating form has two versions, one for preschool/kindergarten and one for elementary/high school. For a child in early intervention, mainstream readiness would be evaluated by the early intervention service provider. Over several days, the provider would observe behaviors to provide a basis for the rating. The AMP requires the service provider to rate a general percentage of time a particular behavior was observed. The following scale, modeled on a bell curve, was utilized: 0%–4%, 5%–25%, 26%–50%, 51%–75%, 76%–90%, 91%–100%. Children who are successful in the mainstream are often scored at 76% or greater on positively worded questions (Chute, 2002).

The pre-K/kindergarten version assesses a child's:

  • General response to speech/music
  • Attempts to communicate through speech/other modality
  • Communication frustration
  • Leadership
  • Initiation of peer interaction
  • Turn-taking skills
  • Imitation
  • Small group activity interaction
  • Distractibility
  • Risk-taking
  • Ability to follow classroom routines
  • Confidence
  • Play skills

The questionnaire for students in elementary and high school is completed by the classroom teacher and includes information about the educational setting, including physical configuration of the classroom and class size, and a description of all services the child receives. A six-point assessment scale is used to rate the child across various instructional and social domains. The teacher is asked to provide a class ranking of the child with a cochlear implant relative to his/her classmates.

The elementary/high school version assessesd the student's:

  • General response to speech
  • Response using speech/other modality
  • Response to communication breakdown
  • Spontaneous imitation ability
  • Ability to follow instructions
  • Attention during teacher-directed activity
  • Level of participation in an activity
  • Ability to comment (e.g., on-topic, off-topic, or enriching)
  • Comprehension of instruction
  • Ability to indicate lack of comprehension
  • Recitation behavior
  • Turn-taking skills
  • Distractibility
  • Participation in group discussion
  • Ability to follow classroom routine
  • Willingness to take learning risks
  • Leadership

—by Patricia M. Chute and Mary Ellen Nevins


Anderson, K. (2002). Early Listening Function. Hearing Review, 9(11), 24–26.

Anderson, K. (1989). Screening Instrument for targeting educational risk (SIFTER) in children with identified hearing loss. Tampa, FL: Educational Audiology Association.

Anderson, K. & Smaldino, J. (1998). Listening Inventory for Education. Tampa, FL: Educational Audiology Association.

Chute, P.M. (2002) Assessing Mainstream Performance in Children with Cochlear Implants, 7th International Symposium on Cochlear Implants in Children, Manchester England.

Chute, P.M., & Nevins, M.E. (2006). School professionals working with children with cochlear implants. San Diego, CA: Plural Publishing.

Francis, H.W., Koch, M.E., & Niparko, J. K. (1999). Trends in educational placement and cost-benefit considerations in children with cochlear implants. Archives of Otolaryngology Head Neck Surgery, 125(5), 499–505.

Geers, A.E., & Brenner, C. (2003). Background and educational characteristics of children implanted by five years of age. Ear and Hearing, 24(Suppl1) 2S–14S.

Nevins, M.E., & Chute, P.M. (1995). Success of children with cochlear implants in educational settings. Annals of Otology, Rhinology, Largynology, Suppl. 166, 100–102.

Nicholas, J.G., & Geers, A.E. (2006). Effects of early auditory experience on the spoken language of deaf children at 3 years of age. Ear and Hearing, 27(3), 286–298.

Spencer, L.J., Barker, B.A., & Tomblin, J.B. (2003). Exploring the language and literacy outcomes of pediatric cochlear implant users. Ear and Hearing, 24(3), 236–247.

A Comprehensive Audiologic Management Plan

by Linda Thibodeau

Management of a school-age child with hearing loss is a coordinated effort among the audiologist and others who serve the child, including the classroom teacher, speech-language pathologist, itinerant teacher of the hearing impaired, resource teacher, and parents. The educational management plan for students with hearing loss can be divided into three components—assessment, the TELEGRAM management program, and treatment plan—with technology as a key part of these components.


Assessment of hearing loss for educational purposes includes the basic audiometric protocol with speech recognition in quiet and noise, if possible. The results must be recorded onto the appropriate forms for determination of eligibility and services. Prior to initiating speech-language or academic assessments of students with hearing loss, a thorough electroacoustic analysis of their hearing aids is necessary. If the student wears a CI, a listening check via the listening earphone should be completed prior to behavioral evaluation of speech recognition. If the student uses a hearing aid, the gain and output of the instrument must be appropriate according to real ear measures and established amplification fitting protocols. Likewise, the CI program must be adequate so that the student is able to show improved speech recognition with the implant. The assessment also may include a classroom observation and completion of an FM questionnaire (see "Educational Audiology Web Sites").

Once the assessment is complete, a recommendation for educational placement, services, and assistive technology can be made and the TELEGRAM—a comprehensive management program—may be considered. The components of this plan, outlined below in order of the acronym letters, do not reflect actual priorities.


The second component to comprehensive management can be summarized by the acronym TELEGRAM, a word that symbolized an effective means of communication before the advent of cell phones and computers. Originally developed for use with adults (Thibodeau, 2004), TELEGRAM allows a clinician to summarize rehabilitative needs across key areas:

T–telephone communication







M–members of the family

The Pediatric TELEGRAM is a service model for children (Thibodeau, 2006); the current modification, the Educational TELEGRAM, provides a framework for the coordination of comprehensive services.


The educational audiologist should determine the best way for the child to communicate over the phone. Telephone communication is not typically part of educational services, but telephone features in hearing aids and cochlear implants offer improved telephone communication and facilitate coupling with classroom amplification systems. For example, a child may have a "microphone + t-coil" program that allows the child to use a neckloop for delivery of the FM signal.


The management of a child's educational needs may vary depending on the level of service provided. A child served through a regional day school program has convenient access to professionals who are trained to work specifically with children with hearing loss. Therefore, less coordination may be required because teachers or professionals trained to work with children with hearing loss may be aware of the child's specific needs or technology or have frequent contact due to the proximity of services. A regional day school program may employ an SLP and audiologist who would facilitate daily communication about technology or other accommodations.

When services are provided at the neighborhood school, professionals trained to serve students with hearing loss would likely provide periodic itinerant services, if needed. In this setting, the audiologist plays a greater role in the in-service training and subsequent follow-up with regular education personnel.


Many families are aware of admission, review, and dismissal (ARD) meetings and three-year re-evaluations required by the Individuals with Disabilities Education Act. However, families may be unaware that if a mainstreamed student is denied assistive technology through an Individualized Education Program (IEP), technology may be acquired through Section 504 of the Rehabilitation Act of 1973.


School-wide assemblies are provided for educational and entertainment purposes. During these events, assistive technology is often left in the classroom, and students are unable to understand a significant portion of the program. A student's FM transmitter can be interfaced with the public address system through the use of an audio cable and direct audio input connection on most transmitters. At a minimum, the FM transmitter microphone can be placed next to the microphone used by the main speaker.


Typical educational settings involve group instruction that pose communication challenges because of background noise and distance from the speaker. Therefore, the use of technology such as a personal FM system should be considered. The FM system should be selected and fit by an audiologist who follows guidelines established by the American Academy of Audiology (2009). The FM fitting should be verified electroacoustically and behaviorally to ensure the settings are optimal.

During classroom-based small-group activities, the student may be able to place the FM transmitter in the center of the group. Some FM transmitters offer an option of using an omnidirectional conference microphone that picks up conversation around a table.


In schools, recreation refers to extracurricular activities such as cheerleading, sports, choir, band, orchestra, and clubs. School-sponsored activities will need to be acoustically accessible. It is unacceptable for a student to be ineligible for the basketball team because he was 30 minutes late to the tryout because the time change was announced verbally in a crowded, noisy locker room.

Auditory perception of extracurricular activities can be particularly challenging because the distance from the speaker and background noise are even greater than in the classroom. Evaluation of the student's auditory perception in these settings is critical and assistive technology must be provided when needed.


Two main alarms are important: fire alarms and alarm clocks. Although schools are typically equipped with flashing smoke alarms, some rooms may lack visual alarms. For example, if a student is in theater tech class and works backstage during a production, would he or she notice the fire alarm signal in that location? The school building should be checked to determine the availability of flashing alarms. Although a student may hear the alarm with a hearing aid or cochlear implant, the visual alert is necessary if personal equipment malfunctions.

Members of the Family

The family must support the student's IEP. A student's hearing aids or CI should be functional and brought to school daily. If, however, a family is concerned that a hearing aid may get lost and doesn't allow it to be worn on the bus, the child receives an implicit message that hearing is important only in the classroom. Clinicians can help parents recognize the importance of technology by playing a hearing loss simulation, so that parents realize the sounds their child is missing, followed by a demonstration of the benefits of using FM technology in noisy situations.

Treatment Plan

The treatment plan is the final step in the comprehensive management of the school-age child with hearing loss. The necessary plans for each area of the TELEGRAM can be determined and reassessed at predetermined intervals. An IEP is developed based on the results of initial assessments and the TELEGRAM. The ultimate goal is for the child to receive the optimum auditory signal for all communication activities to enhance learning and retention in the educational setting.

Linda M. Thibodeau, PhD, CCC-A/SLP, is a professor at the University of Texas at Dallas. Her research involves evaluation of the speech perception of listeners with hearing loss and hearing assistance and has been funded by National Institutes of Health, Deafness Research Foundation, and National Organization for Hearing Research Foundation. Contact her at

Educational Audiology Web Sites


American Academy of Audiology. (2009) AAA Clinical Practice Guidelines: Remote Microphone Hearing Assistance Technologies for Children and Youth Birth-21 Years. [PDF]

Crandell, C.C., Holmes, A.E., Flexer, C., & Payne, M. (1998). Effects of soundfield FM amplification on the speech recognition of listeners with cochlear implants. Journal of Educational Audiology, 6, 21–27.

Schafer, E.C., & Thibodeau, L. M. (2006). Speech recognition in noise in children with bilateral cochlear implants while listening in bilateral, bimodal input, and FM-system arrangements. American Journal of Audiology, 15, 114–126.

Thibodeau, L. (2004). Maximizing Communication via Hearing Assistance Technology: Plotting beyond the Audiogram! Special Issue: Assistive Listening Devices. Hearing Journal, 57, 46–51.

Thibodeau, L. (2006) Hearing Aids and Cochlear Implants. In Luterman, D. Ed. Children with Hearing Loss. Sedona, ZA: Auricle Ink Publishers.

Thibodeau, L. (2006). Hearing Aids and Cochlear Implants. In Luterman, D. Ed. Children with Hearing Loss. Sedona, AZ: Auricle Ink Publishers.

U.S. Department of Education. (2007). Building the legacy: IDEA 2004. Retrieved October 29, 2007, from

Find Out More

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  • Serving Multilingual Clients With Hearing Loss


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