Test Equity: Evaluating Deaf Individuals with Additional Disabilities

Donna Morere, Ph.D. Professor of Psychology Gallaudet University Donna.Morere@gallaudet.edu

npydeaf.morere@verizon.net Presence of Additional Disabilities in Deaf Individuals

According to the 2007 2008 Demographic Survey conducted by the Gallaudet Research Institute, it is estimated that 40% or more of deaf children have some additional condition that affects their ability to function (GRI, 2008). These conditions range from ADHD, vision impairments, and cognitive limitations to language disorders, motor issues, and multiple challenges. One of the reasons for this is that in addition to the typical risks for many disabilities, some causes of deafness, such as maternal rubella, meningitis, anoxia, prematurity, CHARGE Syndrome, Rh incompatibility, and cytomegalovirus (CMV), place the child at an even greater risk for many of these conditions (Mauk & Mauk, 1992, 1998; Samar et al., 1998; Vernon & Andrews, 1990). The resulting conditions include Attention Deficit Hyperactivity Disorder (ADHD) and other disorders of executive functioning, learning disabilities (LD), primary language disorders (language delays not explained by the deafness -PLD), intellectual disabilities (formerly mental retardation), vision limitation, Mmtor impairments, Pervasive Developmental Delays and Autism, other medical conditions, and psychiatric conditions. For purposes of education, the deaf child with additional disabilities is often labeled with deafness as the primary disability, with additional disabilities ranked as secondary, tertiary, and so forth, in respect to their relative contribution to the childs risk for academic failure. Many individuals additional conditions are not diagnosed until late childhood or even adulthood as the focus is generally on the deafness. Each individual presents a unique case due to variability in onset of deafness, degree and type of hearing loss, related communication and language delays, and learning styles, and the type, onset, and degree of the additional disabilities. All of these factors interact in ways that are unique to the individual. The interaction of these various impacts affects the deaf persons ability to function in school and at work. For this reason, it is critical that the individual has an accurate evaluation that clearly identifies any additional disabilities and the impacts they will have on the persons functioning.

Age of Diagnosis
Early language exposure regardless of whether it is spoken or signed is critical for the development of language fluency again regardless of the modality of the language (Mayberry, Lock & Kazmi, 2002). It is well known that the early diagnosis of and intervention for - hearing loss is critical for successful language development (Moeller, 2000). The need for early diagnosis of additional disabilities is less well understood; however, as intervention for any additional
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condition will enhance the childs access to both language and the world, early diagnosis and intervention should be the goal for all conditions. The impact of the delay will depend on the type and severity of the disability. For example, if a primary language disorder is not diagnosed and addressed with intensive intervention in early childhood, the language delays may be extreme by the time the child enters Kindergarten, with the result that the child may never develop fluency in any language. Similarly, early limitations in vision or visual processing may limit the childs ability to develop sign language and/or reading skills, again having widespread impacts on academic, social, and vocational functioning. Often the diagnosis is delayed as the focus is on the childs deafness. Additionally, many factors make diagnosis of issues such as language disorders and learning disabilities difficult in a deaf child. Variable language exposure or availability of accessible language makes diagnosis of a language disorder problematic. Furthermore, a deaf child may have been exposed to multiple forms of communication, and determining the language skills themselves may be difficult. To complicate the issue further, current, well validated measures of language skills for deaf children are notably absent. Similarly, identifying learning disabilities can be difficult as academic achievement for deaf children in general has lagged behind their hearing peers. Thus, the childs accomplishments must be compared not only to his cognitive abilities, but also expectations based on his educational access and the outcomes for peers with similar access. For this reason, more subtle limitations, such as learning disabilities, or milder forms of many disabilities may not be diagnosed until middle school or later, with the result that the child struggles to learn despite adequate cognitive abilities. These children are often labeled lazy or underachievers and are at risk for failure. They may experience frustration and secondary psychological sequelae, such as anxiety or depression and are at risk for dropping out of school and continued failure. It is not unusual for even mild to moderate challenges to be overlooked until late in the precollege or even college or adult years.

Evaluators
If we accept that early diagnosis is critical for success, the question arises as to who is qualified to perform such an evaluation. Typically, the diagnosis of a cognitive limitation, a learning disability (LD) or an Attention Deficit Hyperactivity Disorder (ADHD) is made through a psychological or psychoeducational evaluation performed by a Clinical Psychologist, School Psychologist, or professional with a closely related degree. More complex disabilities, such as those involving memory, visuospatial functioning, and so forth, may require the expertise of a Clinical Neuropsychologist. While such expertise in psychology is required, it is not sufficient for the evaluation of this population. The clinician should have expertise in the field of deafness. And understand the impacts of deafness on both the cognitive and emotional development of the individual and the assessment process and outcomes. A person who does not have this expertise may make major errors, such as diagnosing cognitive limitations based on verbal (English-based) portions of an intelligence test. They may also make multiple minor errors, such as not realizing that instructions must be completed before the examinee is expected to start reviewing stimuli, as a person who depends even partly- on visual communication cannot receive instructions and look at the stimuli simultaneously. Ideally, the examiner should have fluency in the primary/preferred mode of
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communication of the individual. Thus, if the person uses American Sign Language (ASL), the examiner should be fluent in ASL. Even if the person functions orally in casual situations, if they depend on sign support in order to have optimal communication, the examiner should accommodate their communication needs. Similarly, if the person prefers sign supported speech, or simultaneous communication, the examiner should be able to meet the individuals needs. Oral evaluation of a person who depends on signs (or Cued Speech) for clear communication access is never appropriate. While at times it may be necessary to perform the evaluation through an interpreter, this must be done with extreme caution and the examiner must understand the potential impacts of interpreter use on the testing process. Use of interpreters who do not understand the testing process can lead to significant errors in diagnosis. For example, an interpreter who is used to casual conversational interpreting may clean up the language of a seriously language deficient client with the result that a language disorder is overlooked and completely inappropriate recommendations made.

Sources of Information
Given an appropriate examiner, multiple sources of information should be used in order to provide the best information. Testing itself is only one piece of the larger puzzle. The examiner should have a referral question which is answered as clearly as possible by the results. Recommendations should address this question as well as any other issues which arise during the evaluation. Information about the persons academic, medical, communication and audiological background should be obtained prior to testing. Whenever possible, the examiner should review reports of previous psychological or educational evaluations as well as relevant medical information. For children, parents or caregivers as well as the client should be interviewed. For adults, parents may or may not be available, but it is often desirable to obtain some information from collaterals, such as employers, spouses/roommates, or adult children of the client, depending on the situation and the ability of the client to provide accurate information. Similarly, information can be obtained, either through interviews or rating scales and reports, from teachers, social workers, and other professionals involved with the client. One extremely important source of information is the observation of the behavior of the client during the interview and testing. How a person performs a task is often more important than how well they perform it. The final piece of the puzzle is, of course, the assessment itself. Here again, it is the pattern of scores that the examiner should consider, and these must be viewed in light of the overall history of the person. Scores in isolation have little meaning, its how they fit with the history and the referral needs that is really important.

Considerations
The examiner should review the information concerning the persons background carefully. The etiology, or cause of the persons deafness, may provide information about potential issues. For example, early experience of bacterial meningitis places the person at increased risk of a language disorder while CHARGE Syndrome increases the likelihood of vision problems, learning disabilities, and social immaturity. The report should reflect awareness of these considerations and their impact on the assessment process as well as recommendations. Similarly, the age at onset of both the deafness and any additional disabilities should be considered. Form of communication used and early language access as well as audiological issues, such as degree of hearing loss, use of assistive technology, and early communication access are critical to the test selection and administration as well as to the understanding of the individuals performance on the measures given. Finally, the examiner should carefully review the persons education. A person who was mainstreamed with an interpreter (or without one) may have significantly different experiences and educational outcomes from one who attended a school for the deaf. It is important to 3

understand the impacts of having attended school where communication was predominantly oral versus ASL or ASL/English bilingual or using sign some form of supported speech. A well written report should include all of this information and address the potential impacts on the assessment process and interpretation as well as on the persons functioning in daily life.

Impacts of Deafness on Tests

Both deafness itself and the primary use of a visual language, such as ASL, can have direct impacts on the test administration and results. Deaf individuals often achieve lower scores than the typical hearing person on measures of linguistic working memory and ordered recall, such as Digit Span and Word Span tasks. This despite the fact that when asked to remember lists of words when the recall can be in any order their performance equals that of hearing peers. In contrast, deaf individuals tend to perform as well as or better than hearing peers on measures of visuospatial functioning. However, they may approach the task in a different manner than is expected of hearing individuals. For example, they may copy designs in a quadrant based manner rather than completing an outline and then filling in details. Awareness of such differences is critical for the examiner to interpret the test performances accurately. Again, awareness of the need for modification in timing of instructions and the demands of visual communication is critical for accurate assessment. It is not uncommon for nave examiners to assume that noise is not an issue for deaf clients. However, few individuals are totally deaf, and auditory distractions can interfere with performance. Similarly, visual distractions can be a major issue, particularly if the client has either attentional or visual difficulties. Finally, the examiner needs to be aware of potential impacts of Cultural Deafness on the assessment process.

Assessment for ADHD, LD, etc.

A good evaluation for a disability related to cognitive functioning, learning or attention should be comprehensive and evaluate the strengths and weaknesses of the individual, not simply test for the deficits. Areas that should be considered include intellectual functioning, language skills, visuospatial and visuomotor functioning (especially for deaf clients), executive functioning, and academic achievement. Areas that will help clarify the persons abilities include evaluation of memory functioning, adaptive functioning, and psychosocial/emotional functioning. Each of these areas will be addressed briefly.

Intellectual Functioning
The most commonly used measures of intellectual functioning are the Wechsler Intelligence Scale for Children and the Wechsler Adult Intelligence Scale, both currently in the fourth edition (WISC-IV and WAIS-IV, respectively). While these are widely used and well validated tests for the general population, they have some significant issues when used with deaf individuals. The Verbal Comprehension and Working Memory Indexes and the Full Scale IQ are not usually valid due to the impacts of English skills and the sequential recall demands. If they are used to evaluate cognitive functioning, the deaf client can have their intelligence significantly under estimated. On the other hand, use of the Perceptual Reasoning Index and/or Processing Speed to estimate functioning may overlook limitations in language skills. Similarly, nonverbal IQ
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tests such as Universal Nonverbal Intelligence Test (UNIT), Comprehensive Test of Nonverbal Intelligence, second edition (CTONI2), etc., may not reflect linguistic intelligence. Thus, a person with a severe language disorder and wide ranging limitations in language related functioning may have these limitations overlooked, while they would be reflected in the evaluation of a hearing person with similar strengths and weaknesses

Linguistic Ability
Measuring language skills is complex when working with deaf individuals. The measures that are appropriate will depend on the language and educational background of the individual. All forms of language used should be examined. Thus, for an ASL user, some measure of ASL, even if it is based on the interview, should be used; however, English skills should also be evaluated. If the person does not use oral communication, this will be restricted to print formats, while a person who uses oral English should have some measures administered in this modality, again even if they are to be used informally rather than for standardized scoring. Depending on the goals of the assessment, simple subtests from a cognitive or academic achievement test battery may be adequate or in-depth language batteries may be required. The latter case may be appropriate if there is a specific question concerning understanding of grammar or similar questions.

Visuospatial & Visuomotor Functioning

Evaluation of visuospatial and visuomotor functioning is particularly important for deaf individuals, especially those depending on sign-based communication. Limitations in these skills can cause secondary impacts on language functioning.

Executive Functioning
Executive functioning represents the general manager of the brain. It is involved in managing attention, both in focusing the attention and in maintaining and shifting it. This is related to cognitive flexibility, or the ability to adapt to change and manage novel situations. It is also responsible for reasoning, problem solving, planning, and organization. It decides what we hold in our memory while we work with the information (working memory). Executive functioning is also responsible for our ability to monitor behavior and others responses to it, and use that feedback to change our behavior (self monitoring) as well as our ability to control our behavior (emotional and impulse control). These above functions enable us to learn from experience and feedback and adapt to our changing world. This area is important for both academic and social success. Problems with executive functioning are seen in a wide range of disabilities, most notably ADHD, autism, nonverbal learning disabilities, and most children with significant language limitations. Evaluation of executive functioning should address all of these areas. Many objective personality and social/emotional ratings have sub scales that reflect some aspects of executive functioning Additionally, there are a number of rating scales that are used to evaluate ADHD that reflect these skills, and the Behavior Rating Inventory of Executive Function (BRIEF) rates the individual on the various aspects of this area. Direct testing requires multiple measures, including testing of attention, cognitive shifting, problem solving, planning and organization, and working memory.
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The Delis-Kaplan Executive Function System (D-KEFS), designed for individuals ages eight to 89, has multiple measures that assess these various skills. While some of the subtests are not appropriate for all deaf individuals due to the English demands, many are visually based and can be used if correctly administered. However, as with all measures, they must be interpreted with the persons history in mind. Similarly, the NEPSY - Second Edition (NEPSY - II), which is normed for children three to 16, has multiple measures of executive functioning which can be applied to deaf children. One advantage of this test is that there are data for a hearing impaired sample in the manual that can aid in interpretation if used judiciously. In general, more weight should be given to the subtests with lower language demands.

Memory Functioning
Memory testing should include evaluation of both visual and linguistic memory. Memory for both pictures (which can be labeled and managed using the internal language of the person) and abstract designs is helpful when evaluating a deaf person. The pictorial memory is especially helpful when measures of language-related memory are problematic, as they may reflect the manner in which the person manages linguistic information. If there are problems with memory and learning, it is helpful to have measures that can reveal if having visual supports for learning of information are helpful or confusing. Both new learning and retention of previous learning should be considered. A number of memory batteries are available, and all include visual components. Signed interpretation of the verbal portions varies in its accuracy and usefulness, and any time these types of tasks are interpreted the scores must be interpreted with extreme caution, as the task itself has changed. Two of the more popular memory batteries are the Test of Memory and Learning, Second Edition (TOMAL-2) and the Wechsler Memory Scale Fourth Edition (WMS-IV). The NEPSY-2 also has a set of memory tests which can be used with younger clients.

Academic Achievement
Academic achievement testing is important for both identification of learning disabilities and determining the impact of other disabilities on academic success. There are a number of academic achievement batteries, including the Woodcock-Johnson III Tests of Achievement (WJ-III), the Wide Range Achievement Test 4 (WRAT4), the Wechsler Individual Achievement TestThird Edition (WIATIII), and the PIAT-R. Each has strengths and weaknesses. The WJ-III has a large number of subtests, many of which can be signed, although, as always, the scores should be interpreted with caution. Although the PIAT-R has older norms and could use an update, it has the advantage that most subtests are multiple choice and therefore do not require spoken/signed responses. This is particularly helpful for the reading measure, which has a sentence the person must read and then must select one of four pictures which best represents the meaning without looking back at the sentence. Reading When looking at reading skills while trying to identify a reading disability in a deaf individual, it is important that the clinician compare performance to standard norms and D/HOH samples as well as the persons own abilities. A two year delay for a congenitally deaf fifth grader may be within expectations compared to standard norms, but if the child has normal cognitive functioning and is two years behind his deaf peers, this suggests something more is happening.
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Typically reading difficulties are associated with either language concerns or difficulty with associating words/signs with symbols (i.e., icons or printed words). One issue with many tests of reading is that most word identification tasks require the client to read a list of words aloud to measure word recognition skills. The hearing person does not have to understand the meaning of the word, only to pronounce it. If the deaf person responds orally, speech production errors may be scored as reading errors. If they sign the words, a completely different task occurs, as the person must not only recognize the word, but attach meaning to it and relate it to the relevant sign in order to respond. This is a higher order task than that which the test is intended to measure, penalizing the signing test taker. Similarly, reading comprehension tasks that use a cloze technique (fill in the blank with a specific word) may be affected by word retrieval or vocabulary issues even when the general meaning of the passage was understood. A variety of reading measures should be considered if this is an important aspect of the assessment. Writing Performance on tasks of writing is typically comparable to the clients reading skills. It is important that ASL-like grammar and omission of articles should not be confused with a writing disability. Learning disabilities often include graphomotor difficulties (typically including poor handwriting) and difficulty with spelling. Math Deaf children without a math disability typically have adequate calculation skills, but language or educational limitations may cause delays in skill development. Applied (word) problems are often affected by English skills. Content areas While content areas dont reflect specific learning disabilities, patterns of difficulties can reveal issues in language or other aspects of learning. These areas are typically tested in English print, but some tasks can be signed. Scores are typically affected by both content and vocabulary, attention, or other types of limittions.

Adaptive Functioning
Adaptive functioning is typically measured by rating scales completed by parents or caregivers teachers, or, for adult clients, the individual himself. These scales reflect the persons ability to perform daily living skills, including motor, social, language/communication, and community skills. Common measures include the Adaptive Behavior Assessment Scales (ABAS-2), Scales of Independent Behavior - Revised (SIB-R), Vineland Adaptive Behavior Scales, AAMR Adaptive Behavior Scales (ABS), and the Inventory for Client and Agency Planning (ICAP).

Psychosocial/Emotional Functioning
Evaluation of psychosocial and emotional functioning provides information about social and emotional factors that could affect performance on other measures, and potential psychiatric conditions that could be present in the individual. Both children and adults are often evaluated using rating scales completed by parents, caregivers, or partners, and teachers or other professionals who know the person well. It is valuable to get multiple perspectives, as a person may do things at school or work that they do not do at home, and vice versa. Examples of these
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types of measures include the Behavior Assessment System for Children, Second Edition (BASC-2) and other child/adolscent scales. Some scales have data on deaf samples in the manual which should be used in conjunction with standard norms to interpret the scores. Many adult scales, such as the Minnesota Multiphasic Personality Inventory (MMPI) are inappropriate for most deaf clients, as both the linguistic complexity and the use of idioms many make the questions inaccessible. Even tests with more accessible reading levels may be affected cultural issues, such as navely honest responding (e.g., I hear things and I dont know where they come from marked true as with residual hearing this is accurate) which may be interpreted as pathology. Direct personality assessments also have significant issues. For example, the Rorschach Inkblot technique is often considered accessible due the lack of reading/writing or English stimuli; however, it is significantly affected by language. Research has found that when responses given in ASL are scored based on English translations, resulted in identification of more pathology than those same protocols when scored directly from the ASL by a clinician fluent in ASL. Drawing tasks are also often used, but interpretation is highly subjective and poorly validated. Thus, a good clinical interview by a person fluent in the clients primary mode of communication is critical for accurate understanding of their psycho-social functioning.

Attention Deficit Hyperactivity Disorder (ADHD)

Prevalence of ADHD within the deaf population has been estimated to be from 3.5 to over 38%, and despite the wide range of estimates is generally considered one of the most frequent secondary disabilities in the deaf population (Kelly, Forney, Parker-Fisher, & Jones, 1993). ADHD commonly co-occurs with LD, emotional concerns such as depression or anxiety, and other issues. ADHD is not simply a disorder of attention, but rather a disorder of executive functioning. Thus, all of the areas described in the discussion of executive functioning may be problematic for these people. They may be disorganized, impulsive, have poor judgment and difficulty with problem solving and reasoning as well as distractibility, inattention, and hyperactivity. Evaluators working with deaf individuals with ADHD should take special care to ensure that the client visually attending when instructions or stimuli are presented (and this should be indicated in the report). As inattention, poor planning, and impulsivity will affect a wide range of tasks, and testing accommodations, such as redirection to tasks and ensuring that the client reviews all choices before responding on multiple choice tasks, may be needed in order to elicit the clients best performance. Deaf individuals with ADHD have additional difficulties as deaf individuals must pay attention to receive language. Thus, a deaf individual with ADHD may have varying degrees of impacts on language development and the acquisition of knowledge, both academic and social. It is important that the clinician consider these impacts when diagnosing co-occurring difficulties.

Learning Disabilities
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Learning disabilities (LD) are difficult to diagnose in D/HOH children as academic delays are often assumed to be secondary to deafness. This is particularly true of language related LDs. Although this is changing, some schools do not dually diagnose deaf children with LDs. In a 1999 survey of educational programs, Jones (1999) found that while most states acknowledge the possibility that children may suffer from both deafness and LD, many of the definitions of LDs were worded to exclude learning impacts that were secondary to deafness. Since it was often considered too difficult to distinguish the impacts of deafness from those of a co-occurring LD, the LDs were generally simply not diagnosed in deaf children. The symptoms and impacts of the LD will depend on the academic area involved, and can affect math, reading, writing, or other specific areas of academic functioning. In order to make an accurate diagnosis and recommendations for accommodations and remediation, it is important that a comprehensive evaluation be performed that evaluates both the underlying cognitive processes as well as all areas of academic functioning. While areas that do not appear to be affected may be minimally tested, it may be necessary to perform in-depth testing of identified areas of need in order to understand the underlying process that is causing the LD so that the most effective interventions can be implemented.

Nonverbal Learning Disability

While there is a controversy concerning the diagnosis of NLD, it is clear that there is a pattern of strengths and weaknesses that may co-occur. The problem areas include processing visual and spatial information, social skills, executive functioning, motor skills deficits, and interpreting non-linguistic aspects of communication (facial expression, posture, etc.). Hearing children typically have strengths in basic verbal skills, but deaf signers may have secondary language impacts. Individuals with NLD tend to score poorly on non-verbal measures despite adequate cognitive skills in daily life. This is problematic for deaf individuals with NLD as when testing intelligence of deaf people, nonverbal functioning is typically emphasized. Thus, the cognitive abilities of deaf clients with NLD may be under estimated, and they may even be misdiagnosed as having intellectual disabilities despite adequate intelligence. Deaf individuals with NLD tend to have difficulty with pragmatics (the social aspects of language), both receptively and expressively. They may understand the literal message, but not the underlying intent of a message. For example, if a frustrated teacher or employer sarcastically comments to a client who is frequently late, Im so glad you decided to come today, the person with the NLD will assume that the speaker is really happy to see them and respond accordingly. This talking at cross purposes may lead to increased anger towards the client, who is assumed to be smarting off. They may also have difficulty with social aspects of communication such as turn taking, and understanding social cues, such as facial expressions and body language. This is particularly problematic for signers, for whom facial expression, posture, and body movements may represent the linguistic message and not just nonlinguistic social cues. Individuals with NLD generally also have difficulty with emotional expression, both in using it themselves and understanding it in others. Thus, they may have a relatively flat presentation, and often misunderstand the intentions of others.

Primary Language Disorders

A primary language disorder (PLD) involves language delays which are not caused by the deafness, and are in significant excess of expectations of the language limitations which can be accounted for by limited exposure to accessible language. Although not caused by the persons deafness, the language delays will be significantly exacerbated by deafness. The diagnosis of a PLD in a deaf person is complicated. Information on the cause of deafness, family history of language disorders or language related LDs, language therapies and interventions, and the persons history of exposure to accessible language is critical. Measures of language appropriate for deaf clients are limited, and testing must often involve standard English-based measures adapted to the language/communication of the person. This should only be done by a person with expertise in the evaluation of deaf individuals as the interpretation will require clinical judgment, since standard scores will have limited validity. The language performance of the individual must be compared to expectations based on their education and language access, as comparison to standard hearing norms leads to false positive. A two year delay in language may be reasonable for a deaf child, particularly one of the more than 90 percent of deaf children who are born to hearing parents. Often, information from teachers who worked with the individual can provide feedback about their performance relative to peers with similar histories. In contrast, excessively low expectations of language in deaf children may lead to false negatives. Thus, the assumption that deaf children will naturally have limited language may result in valid PLDs being overlooked. Individuals with more severe PLDs may require pictorial support for communication. Those with milder forms of the disorder may have difficulty with casual communication and reading. They may benefit from intensive language intervention. If they develop reading skills, they may be better able to understand language in print than signed or spoken language. Unlike those with NLD, they often depend on the nonverbal aspects of communication (facial expression and body language) to understand both the message and intent of speakers/signers. Expressively, they may use limited vocabulary (signed or spoken) combined with gestures and pantomime. They may benefit from simple speech/signing produced slowly with frequent breaks for processing and checks for comprehension. They often have strengths in processing and recall of static visual information, so pictorial supports are typically helpful even for those with milder forms of the disorder.

Other Disabilities
While deaf individuals are at least as vulnerable to psychiatric disorders as the general population, due to the difficulties in assessment, these disorders may be both under- and over-diagnosed in this population. Tests such as the MMPI and Rorschach can suggest psychopathology in psychologically healthy individuals. Furthermore, when communication access is attempted by writing to the client and having them write in response, clients use of ASL grammar in their writing may be mistaken for word salad and result in an erroneous diagnosis of psychosis. This emphasizes the importance of the involvement of clinicians with both expertise in working with deaf people and fluency in the communication mode of the client in the diagnosis of psychological or psychiatric disorders. Deaf individuals may have multiple conditions, including vision and motor issues, as well as any of a range of learning and other disabilities. Many of these conditions interact to make the functional outcome more limited than each disorder in isolate or simply additive impacts. A deaf person with both PLD and ADHD will have more severe language limitations due to inattention.
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The paucity of valid standardized instruments and need for an understanding of both deafness and the interaction of multiple disabilities on performance on the tests that are used makes it imperative that the clinician be both a skilled in assessment and knowledgeable about deafness.

Recommendations
The recommendation section is the most important part of the report. The recommendations should address all of the concerns related in the referral question. They should be practical and doable. That is, the person should have the resources cognitive, physical, financial, and/or social to be able to apply the recommendations take advantage of the recommendations. They should either be clearly explained in accessible language or there should be a reference to a source that explains what is to be done. The recommendations should be relevant to the needs of both the individual and the specific disability. For example, extended time for tasks and tests are commonly recommended for individuals with ADHD. However, often time pressure can help the individual focus their attention, and extended time may simply provide them with additional opportunities for distraction and inattention. The person may benefit more from additional breaks to work off excess energy and re-focus their attention. The recommendations should include any accommodations the person may need, such as breaks, a scribe, pictorial supports, or a calculator. It should also include any relevant interventions. This may involve citing specific interventions, such as types of spelling or vocabulary practice, or referral to a type of intervention, such as referrals for occupational, physical, or language therapy. Attention should be paid to strengths as well as weaknesses. The goal of the recommendations should be to take advantage of the individuals strengths and accommodate or remediate his weaknesses to optimize his functioning. Strengths can be used to both compensate for weaknesses and provide a source of educational and vocational success even in the most impaired individual. A report with this combination of recommendations will enable those working with the individual to help him to function optimally despite multiple challenges.

References
Gallaudet Research Institute (November 2008). Regional and National Summary Report of Data from the 2007-08 Annual Survey of Deaf and Hard of Hearing Children and Youth. Washington, DC: GRI, Gallaudet University. Jones, T. (1999). Can a deaf student have a learning disability? The exclusion clause and state special education guidelines. In H. Markowicz & C. Berdichevsky (Eds.), Bridging the gap between research and practice in the fields of learning disabilities and deafness conference proceedings (pp. 113-118). Washington, DC: Gallaudet University. Kelly, D., Forney, J., Parker-Fisher, S., & Jones, M. (1993). Evaluating and managing attention deficit disorder in children who are deaf or hard of hearing. American Annals of the Deaf, 138, 349-357. Mauk, G. & Mauk, P. (1998). Considerations, Conceptualizations, and Challenges in the Study of Concomitant Learning Disabilities Among Children and Adolescents Who Are Deaf or Hard of Hearing. Journal of Deaf Studies and Deaf Education, 3(1), 15-34. Mauk, G. & Mauk, P. (1992). Somewhere, out there: Preschool children with hearing impairment and learning disabilities. Topics in early childhood special education: Hearing-impaired preschoolers, 12, 174-195.
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Mayberry, R.I., Lock, E. & Kazmi, H. (2002). Linguistic ability and early language exposure. Nature, 417 (6884), p38. Moeller, M.P. (2000). Early intervention and language development in children who are deaf and hard of hearing. Pediatrics, 106;e43, DOI: 10.1542/peds.106.3.e43 Samar, V., Parasnis, I. , & Berent, G. (1998). Learning disabilities, attention deficit disorders, and deafness. In M. Marschark & M. D. Clark (Eds.), Psychological perspectives on deafness, (pp. 199-242). Hillsdale, NJ: Lawrence Erlbaum. Vernon, M. & Andrews, J. (1990). The psychology of deafness: Understanding deaf and hard-of-hearing people. New York: Longman.

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