Integrating into the Hearing World: Inclusion Success Indicators [STUDY]

Facilitators and Barriers to the Inclusion of Orally Educated Children and Youth with Hearing Loss in Schools: Promoting Partnerships to Support Inclusion

Alice Eriks-Brophy, Ph.D, Andrée Durieux-Smith, Ph.D., Janet Olds, Ph.D., Elizabeth Fitzpatrick, M.Sc., Cheryll Duquette, Ph.D., and JoAnne Whittingham, M.Sc.


Abstract

The majority of orally educated children with hearing loss are receiving their schooling in inclusive settings.  Nevertheless, there is little recent research examining their integration experiences.  A series of 10 focus groups with young people with hearing loss, their parents and itinerant teachers of deaf and hard of hearing students were used to identify facilitators and barriers to school inclusion. These facilitators and barriers were found to be associated with teachers and administrators, parents, peers and students with hearing loss. The findings emphasize the importance of examining factors external to individual children and youth with hearing loss in preparing for their inclusion in a standard classroom and support the notion that successful inclusion requires commitment from numerous sources and respectful partnerships among key stakeholders.  The findings of the study have implications for the identification of variables to promote the successful integration of children and youth with hearing loss as well as other forms of communication difficulties.


Introduction

Inclusion is an educational option where children with disabilities pursue all or part of their education within a standard school program with their peers who are not disabled.  In this model, support is provided to both students and teachers in order to facilitate optimal access to learning in the classroom.  An equivalent term, mainstreaming, implies similar educational processes and has traditionally been used by educators of children with hearing loss in order to refer to the education of these children in classrooms with hearing peers (Antia & Stinson, 1999).  Inclusion focuses on the acceptance rather than exclusion of children with various types of disabilities in the classroom, school and wider social community.  The inclusive model also supports and promotes the growth of the child within these environments. Inclusion is seen as having overall beneficial effects and has been reported as a desirable option by parents, educators and integrated students with a variety of disablities (Andrews & Lupart, 2000; Biklen, 1992; Bunch, Lupart, & Brown, 1997; Goodlad & Lovitt, 1993; Green, 1990; Lipsky & Gartner, 1989; Lombardi, Nuzzo, Kennedy & Foshay, 1994; Northcott, 1973; Stoker & Spear, 1984; Winzer, 2002). 

Studies examining the academic achievement of children and youth with disabilities in inclusive programs have demonstrated that these children consistently outperform students with similar disabilities educated in segregated special education settings (Allen, 1986, 1999; Allen & Osborn, 1984; Geers, 1990; Jensema, 1975; Kluwin & Moores; 1985, 1989; Wang & Baker, 1985-86).  These children have disabilities such as intellectual handicap, developmental delay, learning disabilities and hearing loss. Other advantages of inclusion consist of attending a neighborhood school, increased involvement in extracurricular activities with neighborhood peers and greater parental involvement in the education of their children (Bodner-Johnson, 1986; Northern & Downs, 2002).  Students without disabilities are exposed from an early age to students with differing ability levels, leading to greater understanding and acceptance of difference among all children.  Inclusion is thus seen as a means of eliminating the deleterious effects of segregation and the stigma often attached to the student with a disability (Bunch et al., 1997; Gartner & Lipsky, 1989; Guralnick, 1986; Guralnick & Groom, 1986; Mastropieri & Scruggs, 2000; Stainback & Stainback, 1990).

Inclusion of Children and Youth with Hearing Loss

Hearing loss present at birth or occurring in early childhood often represents a significant barrier to the natural acquisition, development and use of spoken language.  The degree of hearing loss as well as any delay in fitting the child with appropriate amplification are two important factors that impact directly on spoken language acquisition.  The resulting language delay often found in children with hearing loss has been seen as an underlying cause of reduced academic performance (Moores, 1987, 1996; Maxon & Brackett, 1992).  Due to this often significant language delay, the placement of students with hearing loss into inclusive settings has been a controversial and highly debated educational alternative.

Nevertheless, since the 1970s, the number of students with hearing loss educated in inclusive settings has increased substantially.  According to recent U.S. statistics, over 79% of school-aged children with hearing loss are being educated in inclusive settings (Easterbrookes, 1999; Luckner, 1991; Nowell & Innes, 1997). Public Law 94-142, The Education of All Handicapped Children Act, passed in the United States in 1975, mandated free and appropriate education for all children with disabilities.  This law stipulated procedural safeguards to protect the rights of children with disabilities and their families and called for non-discriminatory testing, the assurance of an annual Individual Education Plan (IEP) and the provision of educational services in the least restrictive environment appropriate to the needs of the child (Moores, 1987; 1996; Northern & Downs, 2002).   The passing of Public Law 94-142 had a great impact on educational programming available for children with hearing loss, resulting in increased trends toward education of these children in schools with typical hearing peers rather than in separate day schools, residential schools and private programs for children with hearing loss (Easterbrookes, 1997; Moores, 1987, 1996). 

The goal of an appropriate educational placement for a child with hearing loss is to match the needs of the student to the continuum of services available in a school or school district.  No single placement option can or should be considered ideal or even desirable for all children with hearing loss.  Instead, an appropriate educational placement should provide specific services as needed, exert minimal limitations on the social and academic growth of the child, stimulate self-sufficiency and responsibility and provide for the development of the skills, abilities and behaviors required for functioning in the least restrictive environment possible (Sanders, 1993).  

A variety of educational placement options should therefore be available for students with hearing loss within their school districts, representing a continuum of services ranging from minimal to maximal support, depending on the needs of the individual child (Ross, 1990; Tye-Murray, 1998).  These placement options range from specialized residential or day school environments, special classrooms for children with hearing loss within a regular school, standard school placement with special resource room support, standard school placement with services of an itinerant teacher of deaf and hard of hearing students, and standard school placement with only those services accessible to all other children in the school. The latter three educational options constitute various forms of inclusion, where the child with hearing loss spends all or part of the day in classroom with hearing peers. In these options, some accommodations to the educational program may include testing modifications, classroom support and access to assistive listening devices.  However, the curriculum is not usually modified, and children are expected to perform at the same level as their peers with typical hearing in academic subjects (Moores, 1987, 1996; Ross, 1990; Tye-Murray, 1998).

Advantages of inclusion specific to orally educated children with hearing loss include the promotion of social interaction with the hearing world, the availability of typical linguistic and behavioral models provided by their peers, a stimulating and highly oral environment with a richness of linguistic input, an increased opportunity for learning opportunities and access to wider curriculum possibilities than might be offered in a segregated environment (Gresham, 1982; Ladd, Munson, & Miller, 1984; Maxon & Brackett, 1992; Nolan & Tucker, 1981; Northcott, 1984; 1990; Nowell & Innes, 1997; Ross, 1990). Inclusion provides children with hearing loss the opportunity to interact and establish social relationships with their peers with typical hearing, conditions that have been shown to have positive effects on social acceptance, self esteem and the ability to form mature social relations (Antia, 1998).  In order to derive maximum benefit from the inclusive environment, students with hearing loss must be provided with and take advantage of the numerous opportunities for interaction with peers, teachers and educational materials that exist in the educational setting.

Predictors of Successful Inclusion of Orally Educated Children with Hearing Loss

Predictors of successful inclusion for children with hearing loss have typically centered on individual characteristics of these students themselves (Brackett, 1993; Geers, 1990; Geers & Moog, 1989; Goldgar & Osberger, 1986; Moores & Sweet, 1990; Northcott, 1990; Pflaster, 1980, 1981).  These characteristics include early identification of hearing loss, early and consistent use of amplification, early family-oriented infant/preschool programming, an auditory/oral approach to language learning using speech as the primary mode of communication and early placement into regular school (between the ages of 3 and 6) with regular support services as required (Geers, 1990; Geers & Moog, 1987; Northcott, 1990; Ross, 1990; Watkins, 1987; White & White, 1987).   Although degree of hearing loss has often been cited as an important predictor variable (Allen & Osborn, 1984; Brackett, 1993; Geers & Moog, 1987; Karchmer, Milone, & Wolk, 1979; Karchmer & Trybus, 1977; Strong, Charlson, & Gold, 1987 ; Wolk, Karchmer, & Schildroth 1982), this is not supported by all studies (see for example Geers, 1990; Biro et al, 1986; and Goldberg & Flexer, 1993).  Some researchers argue that age at intervention rather than degree of hearing loss is a significant predictor of language outcomes for these children (Apuzzo & Yoshinaga-Itano, 1995; Calderon & Naidu, 2000; Moeller, 2000; Yoshinaga-Itano, 1999).   Parental involvement as an essential co-condition to early identification in achieving positive language outcomes for children with hearing loss is also receiving considerable research attention (Calderon, 2000;  Meadow-Orlans, Mertens, & Sass-Lehrer, 2003; Moeller, 2000; Yoshinaga-Itano, 2000).

Reading and writing ability as well as high levels of speech intelligibility have also been frequently cited as important individual characteristics that impact directly on successful inclusion into mainstream educational placements (Allen & Osborne, 1984; Geers, 1990; Goldgar & Osberger, 1986; Holt, 1993).

Although traditional perspectives on the indicators of success in the inclusive environment attribute such characteristics as residing primarily within individual students themselves, this view has been criticized for ignoring the potential influences of educational and societal contexts on the successful inclusion of children with various types of disabilities.  In addition, such traditional perspectives place undue burdens on the students themselves, holding them primarily responsible for their own success or failure in the mainstream.  Some recent studies reject the view of disability as residing solely in the acts or characteristics of individuals and attempt instead to describe disabilities in terms of societal reactions to these behaviors and characteristics (Antia, 1998; McDermott & Varenne, 1995; Mehan, Hertweck & Meihls, 1986).  According to this expanded view, factors external to the child such as the attitudes of teachers and peers toward their disability and the abilities of conversational partners to organize and adapt interactions and discourse structures to respond to the communicative needs and abilities of these students are equally important considerations in the development of a model of effective educational inclusion.  Available research shows that teacher attitudes toward the inclusion of students with disabilities impact directly on the effectiveness of this educational approach (Bunch et al., 1997).

“Successful” Inclusion for Children with Hearing Loss

There are many opinions but little conclusive recent research on the programming characteristics associated with positive outcomes for children with hearing loss, and no clear definition of what constitutes “successful inclusion.”  The tendency has been to define “success” in inclusive settings in terms of outcomes related to academic achievement, which in turn has been associated with expressive and receptive language skills (Antia, 1998; Goldgar & Osberger, 1986; Moores & Sweet, 1990; Northcott, 1990; Pflaster, 1980, 1981) and performance on standardized measures of reading and writing ability (Geers & Moog, 1989; Luckner & Muir, 2001; McGee, 1990; Powers, 2003). There is, nevertheless, an increasing awareness that a high level of performance in the traditional academic areas of mathematics, reading and language is not sufficient to ensure successful adult adjustment and that success in inclusive settings needs to be defined not only in terms of communication skills and academic achievement but also in relation to the social development of the child with hearing loss (Ross, 1990; Schwartz, 1990).

Kluwin, Stinson and Colarossi (2002) point to the importance of examining the affective functioning and social competence of children with hearing loss as evidence of successful inclusion for these children.  Ross (1990), in his document entitled, “The Mainstreaming Bill of Rights,” outlines ten principles that he believes provide the underpinnings of successful inclusion for children with hearing loss.  These principles emphasize accommodations and supports that must exist within the mainstream classroom rather than individual characteristics of the students themselves.  These supports include the need for detailed planning and close examination of educational alternatives based on the abilities and needs of the individual child prior to classroom placement, in-depth in-service training for teachers and other professionals, ongoing support to students and teachers in facilitating inclusion and the importance of psycho-social considerations in planning for successful educational placements.

Facilitators and Barriers to the Inclusion of Children with Hearing Loss in Schools

This paper presents results of the qualitative findings of a larger study conducted by Durieux-Smith et al. (unpublished data), which investigated current levels of functioning achieved by young adults with hearing loss who had received Auditory-Verbal therapy during their preschool years.  The study was divided into three phases and collected both quantitative and qualitative data using questionnaires, standardized assessment measures and focus-group interviews. The questionnaires were used to collect descriptive information related to the audiological, intervention, educational  and vocational histories of the participants with hearing loss and their parents. Standardized measures of functioning were obtained in the areas of language, academic and socio-emotional functioning.  Inclusion criteria for the study were: a hearing loss requiring hearing aids, enrollment in preschool Auditory-Verbal therapy at the Children’s Hospital of Eastern Ontario (CHEO), no developmental or cognitive disability that would impact on communication ability, English as the primary language of instruction and high school age or older at the time the study was initiated. One hundred one young people with hearing loss met the inclusion criteria for the overall study.  Of these, 64% were successfully contacted.  Forty-three students with hearing loss participated in the questionnaire phase of the study, 24 in the testing phases and 16 in the qualitative component of the study.

The goal of the qualitative component of the research was to verify and extend data obtained through the questionnaires; identify facilitators and barriers to the inclusion of students with hearing loss in the domains of school, family and peers; and develop a set of recommendations for policy and practice that would serve to facilitate the effective inclusion of students with hearing loss in their schools and communities.  Qualitative data were collected through a series of 10 focus-group interviews consisting of (1) guided questions related to participants’ experiences with and perceptions of the inclusion of students with hearing loss in inclusive classroom environments and (2) their recommendations related to effective inclusive policies and practices.

The Ottawa Model of Intervention and Inclusion for Children with Hearing Loss

The research was conducted at CHEO, a regional pediatric hospital in the national capital region of Canada where an Auditory-Verbal approach to speech and language intervention is used.  Auditory-Verbal therapy (AVT) is an intervention approach that promotes the use of amplification and residual hearing to foster the development of spoken language skills in children with hearing loss.  One of the principal goals of AVT is to encourage and support the inclusion of children with hearing loss in typical social and educational environments with their hearing peers.  AVT differs from other auditory/oral approaches in its strong emphasis on the use of residual hearing for the development of speech and language in children with hearing loss.  Additional sources of potential input such as speech reading and tactile information are not directly utilized in this intervention approach.

A key characteristic of the Auditory-Verbal approach is its focus on individualized therapy sessions so that caregivers learn to stimulate language development in everyday environments, and the child is encouraged to use hearing as the main channel for speech reception.  Auditory/oral approaches are concerned with enhancing oral communication through the use of hearing and speechreading, and intervention programs may be delivered through individualized or group instruction programs (Estabrooks, 2001; Schwartz, 1996).

CHEO utilizes a service delivery model that emphasizes the early identification of hearing loss and prompt audiological evaluation and management (Fitzpatrick, 1997).  Ongoing diagnostic evaluation of children with hearing loss is provided within the context of a pediatric hospital-based preschool rehabilitation program in which a close liaison between audiological and rehabilitation services is paramount.  Parents are directly involved in the rehabilitation services provided to their children, and, in addition to developing skill as primary models for language development, they are provided with ongoing counseling and support.  Once the children reach school age, hospital-based therapists assist in facilitating the transition into an established school support system, which has provisions for itinerant teachers of the deaf and hard of hearing, educational audiologists and other resource support.  Itinerant teachers have expertise in working with students with hearing loss.  In addition to providing support services to included students, these teachers serve an important role in consulting and collaborating with school personnel, particularly with classroom teachers on issues related to hearing loss, amplification systems, speech and language development and adapted teaching practices for effective inclusion (Tye-Murray, 1998; Estabrooks, 1994).

Method

All participants from previous phases of the research were invited to participate in the qualitative component of the study.  In addition, all itinerant teachers of the deaf and hard of hearing from the two English school boards in the Ottawa area received invitations to participate in the focus groups.  Participation in the focus groups was voluntary and limited to between six and eight members per group in order to facilitate discussion. 

Participants

Twenty-four parents of young adults with hearing loss participated in four parent focus groups.  Sixteen young adults with hearing loss chose to participate in three focus groups.  Oral interpreters were provided as needed for those who requested such services.  Fourteen itinerant teachers of the deaf representing three school commissions participated in three focus groups. In the original formulation of the study, focus groups were also to have been held with classroom teachers who had taught students with hearing loss in integrated settings in the past.  The political climate related to education at the time in the Canadian province where the study was carried out included a campaign of teachers “working to rule,” an action that precluded them from participating in any school-related activities outside of their direct instructional time.  This was followed by a two-week teacher’s strike. Although some teachers expressed interest in participating, the response rate was inadequate to form a complete focus group. Teacher perceptions related to the inclusion of students with hearing loss have since been elicited through a questionnaire format (A. Eriks-Brophy & J. Whittingham, submitted).

Participants with Hearing Loss
Eight male and eight female young adults with hearing loss participated in the focus groups. These young people had a pure tone average of 84.6 dB (plus or minus 19.5 dB), were fitted with hearing aids at an average age of 1 year, 10 months (range: 4-60 months) and averaged 19.7 years of age (range: 15-30). All but one of the participants used hearing aids at the time of the study. The one individual with a cochlear implant had received her device two years before the research study was conducted.

Participants came primarily from two-parent families (87.5%), with an average of two children per family. In 96% of the participating families, the primary language at home was English. The majority of young adults with hearing loss who participated in the focus groups had been educated in inclusive environments throughout their educational history (71%), whereas 8% reported having been taught in classes for the deaf at some point during their elementary school years, and 21% reported having received some special education services secondary to learning difficulties not associated with their hearing loss. At the time of the study, eight participants with hearing loss were enrolled in high school, four in post-secondary educational institutions and four had completed their education and were participating in the work force.

Parent and Itinerant Teacher Participants
Ten fathers and 14 mothers participated in four parent focus groups.  These participants were the parents of the young people with hearing loss described above. Two of the mothers were single parents.  All parents spoke English in the home, and all but one set of parents represented mainstream middle class cultural backgrounds.  Levels of education of the parent participants were relatively high, with 85.7% of both mothers and fathers reporting having a college or university level of education. The socioeconomic status of the parent participants was also relatively high, with the majority of participants belonging to middle-class or upper-middle-class socioeconomic groups as determined by the professions of the primary wage earner of the family.

The 14 itinerant teachers of the deaf and hard of hearing were all female teachers who represented the two English school commissions in the national capital region. These participants all had over five years of experience working with children with hearing loss. All teachers had a bachelor’s degree in education, and seven were certified Auditory-Verbal therapists.

Apparatus

Focus-group interviews were audiotaped with a Sony BM-246 conference recorder. Separate microphones and channels permitted the identification of individual speakers throughout the recorded interviews.

Procedures

All focus groups were conducted by the same experienced facilitator in order to ensure comparability across groups of participants. In order to test the focus-group methodology and to ensure that the procedure adopted would elicit the information of interest to the study, a pilot focus group with six mothers whose children were still too young to participate in the study was carried out. The pilot focus group resulted in a number of important suggestions that were incorporated into the final procedure. Subsequent to the recommendations of participants in the pilot focus group, for example, participants received an information package containing guided questions prior to the meeting, which served to orient them toward the topics to be discussed.

Each focus group began with an introduction to the study as a whole, an explanation of the focus-group procedure and the signing of consent forms. At the beginning of each focus group, participants were asked to respond to the question, “What factors related to school/home/community/peers acted as facilitators/barriers to inclusion?”, by independently identifying facilitators and barriers to inclusion in these areas on a response sheet.  The focus-group facilitator then went around the table, asking each participant to contribute one of the items they had listed to the group discussion. Other participants voiced their agreement or disagreement with the item mentioned and were given the opportunity to discuss their personal experiences related to the identified facilitator or barrier.

As the discussion continued, participants were asked to contribute additional items that had not been previously mentioned. All responses were listed on chart paper as either facilitators or barriers to inclusion according to the domains of interest. Recommendations for policy in the areas of family, school, community and peers were made at the end of each focus group. Focus groups were held in the late afternoon or evening at CHEO for parents and young people and at the offices of two local school commissions for itinerant teachers. The average duration of each focus-group interview was three hours.

Analysis

Focus-group interviews were transcribed in their entirety. A preliminary analysis was carried out by two independent coders in order to develop codes related to identified facilitators and barriers to inclusion and to extract recurring themes. One of the two coders entered the transcripts and conducted the coding using the CHILDES database (MacWhinney & Snow, 1990), a computerized language analysis system. The other coder entered codes by freehand directly onto the printed transcripts.  Two levels of coding were used in the computerized analysis of participant contributions. The first set of codes determined whether the item mentioned constituted a facilitator or a barrier to inclusion. The second set of codes identified the domain to which the item referred as school, home, community or peers. Analyses were compared, and a final list of codes was derived based on those developed by the two independent coders. These codes were used in the final analysis of the focus-group data.  The computerized analysis permitted the frequency of barriers or facilitators associated with each of the domains of school, home, community and peers to be calculated. Facilitators and barriers had to have been mentioned across all focus groups in order to be included in the list, with the exception of issues related to parents’ emotional responses to the diagnosis of hearing loss, a subject discussed in both parent and itinerant teacher focus groups, but not by the students themselves.

Results

Facilitators and Barriers to School Inclusion

Facilitators and barriers to the educational inclusion of children with hearing loss mentioned by the three groups of participants fell into a wide range of domains.  Subsequent to the coding and analysis procedures described above, these variables were classified and organized into three primary areas: facilitators and barriers related to school, family and community.  Of these, facilitators and barriers to the inclusion of children with hearing loss in educational settings were the most frequent of the variables mentioned by all groups of participants in the focus groups. These variables are described in this article.  Variables associated with the inclusion of children with hearing loss into family, social and community activities and recommendations for the inclusion of children with hearing loss into schools and communities and implications for policy and practice are described in detail elsewhere (Eriks-Brophy, Durieux-Smith,  Olds, Fitzpatrick, Duquette & Whittingham, in press).

The facilitators and barriers associated with inclusion into the school setting were classified according to four primary domains: (1) those related to teachers and school administrators, (2) to the parents of students with hearing loss, (3) to hearing peers and (4) to the students with hearing loss themselves. Excerpts taken from the focus groups are used to illustrate ideas central to the identified themes.  These quotations are presented verbatim as they appeared in the transcripts with the exception of the removal of hesitations, repetitions, false starts and place fillers. All names have been changed in order to protect the anonymity of the participants; however, these names have been used consistently to be able to recognize the voices and contributions of individual participants.

Facilitators and Barriers to Inclusion Related to Teachers and School Administrators

Factors related to teachers were mentioned most often by all sets of participants as important facilitators of inclusion. Of these, the role of the itinerant teacher was the most frequent and important facilitator to inclusion mentioned across all groups.  As one of the itinerant teachers mentioned in response to the question regarding facilitators to inclusion, “Well, the first one’s easy. The reason these kids are so successful in school is because of us!”  The essential role of the itinerant teachers in facilitating inclusion was strongly present in every focus group and is highlighted in the following quotation from one of the parent focus groups.

Liz:  The itinerant teacher was the most important as far as I'm concerned; that is absolutely number one because we didn't have any idea what to do.

Diane:   Essential.

Linda:  Itinerant teachers.  These people are lifelines or whatever, I mean you can't sing their praises enough.

In the Ottawa model, itinerant teachers provide the bulk of services for included students with hearing loss. The important roles ascribed to itinerant teachers as facilitating inclusion included developing individualized programs to promote language, social and academic skills suited to the needs of individual students with hearing loss, sensitizing classroom teachers and peers to issues related to hearing loss and the use of assistive technology, consulting regularly with classroom teachers and coordinating school-based services and programs.

Itinerant teachers organized a workshop at the beginning of each academic year for all teachers within the board who would have an integrated student with hearing loss.  These workshops were described as an important forum for sensitizing classroom teachers to the needs of students with hearing loss as well as for the provision of basic information on hearing impairment, hearing aids and assistive technology.  Additional support provided by resource teachers, speech-language pathologists, teacher assistants and the occasional oral interpreter were also mentioned by all groups as being essential to successful inclusion when they were available.

Cooperative principals who supported the roles of support professionals both administratively and in budgetary considerations were mentioned by all groups as essential to successful inclusion.  Effective principals promoted a team approach to case management that emphasized the inclusion of parents as experts about their own children. Other characteristics of administrators seen as facilitating inclusion included provisions for the continuity of services from support professionals for an individual child over several years, the establishment of an atmosphere of acceptance within the school, the development of a strong volunteer network in the school and a sensitivity to the need for a reduced teacher-student ratio in classrooms containing integrated students with hearing loss. The importance of the attitude of the principal in promoting inclusion is reflected in the following interview excerpt from one of the parent focus groups.

Mary:  The whole attitude throughout the school starts at the principal.  If the principal says, “I’m for this,” it all just follows right along.

Dave:  That’s right.  If he supports it, the teachers seem to fall in line.

Classroom teachers who had positive attitudes toward the concept of inclusion and who were flexible in their attitudes towards assignments and testing, open to the suggestions of the itinerant teachers and sensitive to the needs of students with hearing loss were seen as essential to facilitating inclusion.  In many cases this could be reduced to the attitudes of individual teachers who “felt they could make a difference” in the education of the child with hearing loss.  These teachers provided students with individual attention, adopted facilitative teaching strategies, communicated regularly with parents and were supported in their efforts by their school administration.  These characteristics are summarized in an excerpt taken from one of the itinerant teacher focus groups.

Shirley: Right up there is good classroom teachers who are supportive of having a hearing impaired child in their class, one who’s open to the suggestion of the itinerant.

Lynn:  I would certainly say the preparation by the teacher of the hearing impaired prior to the student coming in is of tremendous value, and the positive attitude of the teacher receiving the child.  If the teacher is negative about receiving the hearing impaired student, it’s a barrier at the start…I’m not sure exactly how to put it but it’s the idea that the classroom teacher is going to make a significant difference in this kid’s life. Somehow, you have to communicate that.  You know, sometimes when they get these little hearing impaired kids and they can’t understand them, and it’s like, “How are we ever going to make this work?”, and you know that they can; and it’s almost by us as itinerants, you’re constantly working with them and believing in our students, and somehow the teacher picks that up too, that they’re going to make a difference.

The use of facilitative teaching strategies such as facing the class while speaking and providing preferential seating to provide access to lip reading, writing notes and assignments on the board, providing class notes, speaking at a slightly slower rate, facilitating the use of buddies and notetakers in class and providing hands-on opportunities for learning such as labs and small group discussions were some of the strategies mentioned by the participants as essential to successful inclusion.  Using assistive technology such as FM systems and closed caption videos in teaching was essential to obtaining access to information presented in class. It was emphasized that such technology should be accessible, up-to-date, maintained in good working order and not forced on the student.  Students expressed some ambivalence about the benefits of FM systems, particularly during the high school years.  While they recognized that the use of technology could facilitate classroom understanding, the potential spotlighting effect of wearing the technology was also discussed. This attitude is succinctly summarized in the following student focus-group excerpt.

Maggie: Some things, they both support and they are barriers at the same time.  Like the FM system, it’s a support but it’s also a barrier because it sets you apart from your friends.

Not surprisingly, a large number of barriers to effective inclusion for students with hearing loss were associated with factors related to teachers and administrators.  First, in order of frequency, were classroom teachers who lacked information, preparation and/or interest in understanding the effects of hearing loss on communication development and academic performance or who were unwilling to invest the additional time and effort that might be required to teach these students effectively, as pointed out by parent participants in the study.

Linda:  And that became a barrier.  Those teachers who either didn’t have the knowledge base or had it but didn’t have the skill or the interest to hang in there and bring out the best in this child in terms of learning.

Karen:  My negative was also the lack of knowledge of the teachers or maybe even the “Oh we have the hearing aid on, he can hear now.” Not realizing that in group activities he has not a clue what was just discussed, so therefore he is not participating.  He hasn’t got a clue, really, what has gone on in class that morning.

All participants described teachers who had negative attitudes toward inclusion in general or towards integrated students with hearing loss in particular, who were inflexible in their teaching and evaluation strategies, and who were unwilling to maintain communication with parents and solicit their involvement in the educational process. These perceptions were eloquently expressed by students with hearing loss themselves, as illustrated in the following excerpt.

Brian:  There is no Romeo and Juliet that I’ve ever found on videotape as closed captioned, except for the Leonardo DiCaprio tape.

Facilitator:  Ok, so it’s not just that they wouldn’t use it.  The alternatives don’t exist?

Brian:    No, no they didn’t try to go out and see what else there is out there.

Facilitator:  Ok, so that’s the key.  That they didn’t look for other ways.

Brian:    Yes.

Tracy:   It would be nice if the teacher would write up the script, but they would say, "Oh, gee that’s extra work!  Maybe I should, maybe I shouldn’t, who knows."  But it depends if we think it’s important.  If everybody else is getting the experience, you can’t take away my opportunity because it’s extra work for you or because you don’t value it and anyhow, "It won’t be on the exam."

Underestimating the potential or abilities of students with hearing loss, having reduced expectations with respect to learning or social behavior and drawing excessive attention to their hearing loss were obstacles to inclusion expressed by all participants, but most eloquently by students with hearing loss themselves, as the following excerpt illustrates.

Tracy:  Another one was unknowledgeable teachers in school.  Teachers who have never encountered deafness, so you’ve got to start from the beginning.  Most teachers are scared.  You wouldn’t expect that reaction, but teachers are very uncomfortable because it is new to them.  So I would fortunately have my itinerant teacher set the whole thing straight, let them know what my abilities are, what my limitations are, rather than having them define it for me.  Because sometimes they would be wrong.  They would think “Tracy can’t handle whatever,” when I can, so don’t restrict me from doing so cause you have an assumption!

Jennie:  And some teachers tend to be...not like a bad attitude, but they tend to overcompensate, which drives me nuts.  Like I had this horrible teacher in grade seven and the first day of school she starts right away... she’s trying to make my friends, fit in with everybody else.  Right off the bat she tells everybody that I’m special and I’ll be treated specially. (Other students laugh).  It took me a while to get over that!

Additional barriers associated with classroom teachers included an unwillingness to utilize assistive technology and to learn to use adapted teaching strategies in order to make information more accessible to students with hearing loss in the classroom.  

Meg:   I had this math teacher this year.  He’s bad!  I mean, I went into his class and told him I was hearing impaired so I wanted to explain the FM and he says, "I don’t understand you!"  I know it takes time sometimes for people but still,  how can he say “I don’t understand you?”  So I said, "Ok, you have to wear this microphone."  And he said he didn’t want to wear that thing and he just can’t believe it.   He said, "I don’t want to wear anything on my shirt," and puts it on the desk and leaves it. 

Technology that was outdated or in poor working order was mentioned as an important barrier to inclusion.  In addition to providing resources for the purchase and maintenance of this equipment, the itinerant teachers in particular often mentioned the importance of encouraging the families as well as the students with hearing loss themselves to take responsibility for the proper functioning of hearing aid technology.  As the itinerant teachers stated:

Patty:   Really, I had a student, no batteries in the implant, you know?

Lynn:   Dead batteries.  For a year and a half, a year and a half, we struggled with batteries in the implant, well no batteries, we’re not getting too far so… at some point, the child, if they’re an outgoing enough personality and they care enough, they’re going to tell you.  And in fact, some of these children that are doing so well with their hearing and their hearing aids, it is a traumatic crisis in their day if the battery is weak or dead and they might as well go home because it’s so upsetting to them.  And then there are the other kids that ...they finish their whole school day and you discover the battery’s been dead and the child didn’t notice or didn’t care.

While itinerant teachers were only rarely mentioned as barriers to inclusion, those itinerants who were inflexible in scheduling individual sessions with students according to their class schedule, who set limits for the student with hearing loss such as opposing enrollment in music or French classes and who “spotlighted” the student with hearing loss by drawing excessive attention to their hearing difficulties were perceived as barriers to inclusion. An excerpt from one of the student focus groups illustrates this attitude.

Brian:  I’ve  got one. Independence. I wasn’t given my independence in high school. I used to see my itinerant teacher twice a week and I wanted to take music.  I wanted to fit in more, I wanted to be more dependent on myself and not on my itinerant teacher.  At first she [the itinerant teacher] refused to let me.  I went on strike.  I didn’t bother showing for class with her.  I just totally acted as if I didn’t have an itinerant teacher at all.  You know, I would show up to class and just sit there and wouldn’t do anything.  And finally she let me take music, which got me more involved with the other students.  So I wasn’t separated from them as much anymore.  I got to play the drums because you can feel the vibrations from the drum, and that was cool!

In addition to respecting their opinions related to their selection of electives within the school curriculum, students with hearing loss also stressed the importance of allowing them to have input on decisions related to the use of assistive technology in class, especially during the high school years.  Outdated equipment was perceived as constituting an additional barrier to inclusion by the students themselves.

Brian:  One other thing is, my FM systems were outdated.  I was never given top quality.  I wasn’t given that until later on, and then I stopped using them. When they did give something that was good, I took advantage of it when I needed it, and then afterwards it came to a point where it’s a hassle to carry it around.  Especially in high school, it doesn’t look good on you. You want to look nice, but you’ve got this big box on your chest and everyone stares at it.  So I just dropped it.

Facilitator:  Does anybody use it?

Mike:  I still don’t wear it that much, but I just don’t tell anybody.  I wear it maybe for two classes, three classes.

Facilitator:  So it’s really best if it’s your choice I guess.

Mike:  I try to make it my choice, yes.

An important administrative barrier to effective inclusion was the lack of openness to a team approach to inclusion that included parents as partners in decisions related to their children and a recognition of parents’ expertise related to hearing loss as well as their own children.  As one group of parents stated:

Sandra: They would try to tell you that it was a team approach.

Mary:  That it was the parent as well as the teacher as well as the community and so forth, and that was extremely frustrating. 

Sandra: I wished at times that they would use me as a resource, and they weren’t willing to do that.

Additional barriers related to administrators included a lack of consistency in services provided to students with hearing loss, placement of students with hearing loss in classrooms with large student-teacher ratios, a lack of budgetary consideration for the purchasing of assistive technology and acoustic modifications in classrooms and a lack of commitment to the allocation of funds for resource support services for both teachers and students.

Janet: For years and years when I was on the Special Education Advisory Council, and even after I left, we tried to communicate the fact that our kids were successful in large part because they had the services.  That’s an essential part of it.  Whereas the trustees would often look at it like, “Well, these kids are doing ok.  They don’t need this.  Let’s take the money from this area because we need to find X numbers of dollars.”

Frank: You’ve got to get the message across that you are investing in these kids and you are going to get results.

Facilitators and Barriers to Inclusion Related to Parents

Facilitators of inclusion at school related to the roles of parents were second in order of frequency across the focus groups.  Facilitating school inclusion for parents revolved primarily around parental involvement in education, which fell on a continuum from school advocacy to home-based actions and activities.  These facilitating factors ranged from parental assertiveness and advocacy skills to a willingness to be actively involved in the education of their children. 

An assertive attitude and active advocacy for obtaining essential services for their children in the school setting were deemed as being essential to achieving the aims of inclusion.  As expressed from the perspective of the itinerant teachers:

Marie:  We’ve often talked about the parents being very assertive, almost to the point of…

Facilitator: So that’s one of those that can show up on both sides, depending on how it’s handled.

Lynn:  Yes, very much so.  Often the parents that can get the most for their child is the parent that the school considers to be a pain in the neck, but we feel she’s going to get what she wants for her child.

Examples of strategies whereby parents acted as advocates for their children included becoming aware of educational policies and procedures relating to classroom placement and evaluation of progress, membership on local school board or parent committees, and attending program review committees.  These forms of involvement were seen as essential to successful inclusion.  As one parent stated:

Liz: I had this really as a recommendation for new parents, but I think being involved and informed are absolutely critical.  All the way along you have to do your homework, know the system, be known, get to know teachers, administrators, get them to know you.  So being involved and informed is, I think, essential...you don’t just appear when there is a problem.  They get to know you as a person and you have credibility and that really helps, so I can’t emphasize that too much.

Frank: Part of it is also understanding the bureaucracy in which the system operates, like knowing what’s involved in an IPRC [Individual Program Review Committee] meeting and what is acceptable to say and what isn’t.

Building a positive relationship with itinerant and classroom teachers and administrators and maintaining frequent contact with the school were seen by all participants as crucial components of effective inclusion. Arranging regular meetings with teachers and the principal, ongoing awareness of and involvement in school events and activities, serving as parent volunteers in the classroom and the school, facilitating transitions when changes in classroom placements occurred and informing teachers at the beginning of the school year about the specific needs of their children were perceived as being essential to successful inclusion.  Contact between parents and teachers was maintained through personal communications, telephone and communication books, which were described by many parents as something they could not have done without. Other home-based activities included helping with homework, following up on topics and concepts discussed in class and ongoing and often intensive work on the speech and language development of their children.  The essential commitment of parents in helping their children succeed in the integrated setting was summarized in one of the itinerant focus groups.

Shelley: The parents who are knowledgeable and supportive, so they can support what the itinerant is trying to achieve and also the classroom teachers.

Lynn:  I was going to say pretty much the same thing as Shelley, I mean, parents who follow through in homework with their child, and by the homework, I mean homework from the itinerant teacher as well as the classroom teacher.  We often send home, say, vocabulary that needs to be worked on or speech targets. It’s very evident which children are worked with and which ones are not.

Students with hearing loss were themselves well aware of the considerable time and effort their parents had expended on their behalf and were highly appreciative of their parents’ commitment to their education and development, both during their preschool and school-aged years.  Recognition of their parents’ efforts permeated the students’ responses to questions of facilitating inclusion.  Perhaps one of the most eloquent of these was stated in the interaction between two of the young participants.

Brian:  The best thing for me was my mom.  She got involved in the school, she became a part of the programs and she stood by me every step of the way, no matter what school I went to or whatever, she was always there.

Tracy:  I guess you owe her a big Mother’s Day gift.

Brian:  One that empties my wallet!

Barriers to inclusion in the domain of the school which were associated with parents included unfamiliarity with the educational system and parents who lacked advocacy skills, were perceived as annoying or excessive complainers by the school staff or did not have sufficient time, skill, or knowledge of language stimulation strategies to work with their children at home.  As one of the itinerant teachers stated:

Patty: There are the parents who are natural language communicators, and there are those who are not natural language communicators and whose level of language is such that communication is practically impossible because they’re always talking in rhymes, and with puns and they don’t realize that they’re constantly putting barriers to communication with their child because of the language that they use.  And it’s their own personal style, and if their language style is not a very productive language style, then it can be particularly difficult for their children.

In addition to difficulties with parental communicative styles, the itinerant teachers in particular mentioned problems associated with parents who abdicated responsibility for their child’s learning once they reached the school-aged years, rather than maintaining an ongoing involvement in their child’s educational progress.

Lynn: A negative, and I don’t know whether we covered it already, but the parent who sort of hands over the responsibility of their child’s education to the professionals, they sort of step back, and say, "Now they’re at school, you do it."

Itinerant teachers clearly had high expectations of parental involvement in the education of their children and the domains in which this involvement should optimally be demonstrated.   These high levels of parental involvement in school activities and supports to learning at home implied a significant time commitment on the part of one or both parents.  Although parents also recognized the importance of their commitment to working with their children and helping them keep up with their peers in the integrated setting, their description of the intensity of that commitment points to elements not mentioned by other groups of participants.  As one parent stated:

Pam: When I look back I’m overwhelmed sometimes at the hours and hours of work after school that you did in elementary cause it was the new language, the new vocabulary, the going back over a concept if it wasn’t understood, to change it to a different way to say it.

Facilitator: So it wasn’t just parental involvement as a volunteer in school.

Pam: Oh no! It was parent’s involvement at home!

Itinerant teachers also mentioned the advantages of encouraging one parent to stay at home to stimulate the child’s speech and language development and to attend weekly therapy sessions as an important component of early intervention.  They nevertheless acknowledged the financial burden this might impose on individual families.  As a result, financial considerations related to the possibility of one parent staying at home became either a facilitator or a barrier to inclusion depending on family circumstances.  As the parents themselves stated:

Janet: This business of volunteering in the schools comes from the fact that you are able to financially afford to have one parent stay at home for at least, say, the first four or five years.

Karen: That’s important.

 Frank: That’s a barrier.

Janet: It can be a support, but it’s also a barrier depending on your circumstances.

Facilitators and Barriers Related to Hearing Peers

Peers were perceived as acting either as facilitators or obstacles to the inclusion of students with hearing loss in the school setting, depending on their attitudes and sensitivity to hearing loss and the needs of their peers with hearing loss.  Peers who acted as note takers, as “buddies” in the classroom and as communication, academic and social interpreters for students with hearing loss were important facilitators of the inclusion process.  These peers were described as being sensitive to the needs of the students with hearing loss without making them feel conspicuous or overemphasizing the hearing loss.  They adopted strategies that facilitated communication in both academic and social settings, allowing the student with hearing loss to follow along more easily in difficult listening situations.  As stated by one student with hearing loss:

Alison: The best thing that I remember was the buddy system.  I had a best friend in the   class who always helped me with assignments or with what was going on the class.  I could always turn to her, she was my student interpreter at the time.

Attending the neighborhood school with the same peer group over time was also mentioned by all participants as an important facilitator to inclusion, as these peers came to understand the student with the hearing loss and were able to explain hearing impairment to others.  Peers were often able to act as social interpreters for students with hearing loss, translating unheard or misunderstood information easily and without being asked. Having had siblings who attended the same school was perceived as facilitating acceptance of the child with hearing loss in the local school.  The importance of early acceptance, established long-term relationships and unspoken understandings was mentioned by all participants but was particularly emphasized in the interviews with the students with hearing loss:

Maggie: Something that has been helpful is going to school with the same group of friends, some of them since nursery school and most of them since grade one, so they know me.  They know they are supposed to turn and look at me. They explain to new people, like, "What’s with that girl over there?" "Oh, she’s hearing impaired."  That sort of thing.

Facilitator: So the same group, and they know the techniques...

Maggie: Yes.  

Jennie:  Well, basically, sort of the same group of friends...They know all the stuff about me.  Cause most of my friends have, somehow after spending a couple years with me they sort of automatically have trained themselves to talk clearly when they are talking to me and stuff like that.  It becomes instinct. 

On the other hand, peers who had a negative or apathetic attitude towards the student with hearing loss, who were insensitive to the needs of the student with hearing loss or who did not use facilitating communication strategies in communicating with the student were described as constituting barriers to inclusion.  Resentment towards the child with hearing loss as a result of perceived favoritism or reduced classroom demands was a barrier associated with hearing peers. All of the students with hearing loss also recollected experiences of children who teased or made fun of them or who intentionally excluded them from social activities during school. These attitudes were perceived as being stronger and more hurtful in the later elementary and high school years as compared to the early elementary grades.

Meg: Because I was the first [student with hearing loss] in my school board, I was basically a freak.  So I hated that. I felt really isolated by the time I got to high school...I think that when you’re little it doesn’t matter as much, people all belong and they might forget about it a minute whereas in high school they remember and you remember and you build a grudge.  So it’s more painful.

Facilitator: Anything else?

Maggie: Just peers.  The sort of thing, like, people say things like, "You can get off easy because you’re hearing impaired.  You don’t have to work as hard."  Only we have to work like 10 times as hard to make up for what we miss and maybe we get to write our exams some of us at a different time but it’s just that we have to work harder, advocate for ourselves and some people resent it, having to acknowledge us.  That sort of thing.

Parents and itinerant teachers often referred to the social isolation and loneliness of students with hearing loss in the inclusive environment.  This loneliness was perceived as stemming from a lack of access to information as well as the difficulty of participating in common adolescent social activities such as using the telephone and going to movies and dances.  As some of the parent participants stated:

Doug: The lack of friends and peers.  Like the lack of acceptance of these kids in the school by the peers.  In my mind, this is a big time barrier to inclusion in normal school!  The lack of friendship that these kids have and how lonely an existence they live on a day-to-day basis in school.  Even inside the classroom. They miss everything in the classroom!

Mary: They miss jokes.  People don’t want to say things a second time.  The latest movie...

Doug: They can’t hear the public address system in the morning or they pretend quite often to hear a joke or laugh when everybody else is laughing, and they missed it completely.  So that to me is a major barrier to inclusion in the normal school.

Facilitators and Barriers Related to Students with Hearing Loss

A number of characteristics associated with students with hearing loss were seen as being important to the facilitation of inclusion.  These facilitators and barriers are subdivided into those related to the preparation of students with hearing loss to learn in integrated environments, and the attitudes of the students themselves within the integrated environment, particularly with reference to the use of self-advocacy skills.

Not surprisingly, adequate speech intelligibility, well-developed communication abilities, auditory skills, reading abilities and good organizational skills were highlighted by all participants as essential to successful inclusion.  These skills were perceived as having been developed through the early identification of hearing loss and subsequent participation in preschool Auditory-Verbal therapy through the CHEO program.  The model of service delivery provided through the CHEO program was described by all participants as having been critical to the development of the auditory skills and the speech and language base essential for inclusion.  As stated in one of the itinerant focus groups:

Lynn:  I don’t know, this is stating the obvious, but certainly, a child who’s had Auditory-Verbal training before they enter school, they’re starting on a much higher level than somebody who’s beginning school having had no training.  Maybe that should have been the first one!

Patty:  Yeah, yeah, I just sort of took that for granted.

The students themselves recognized the importance of the preschool language intervention they had received and its link to their current levels of success and the education options that had been available to them.  The skills provided to parents in developing speech and language skills through the CHEO model as well as the central role and commitment of parents in the early years within this model are also reflected in the excerpt taken from a student focus group.

Jennie:   Also what was really important was obviously, CHEO.  Learning how to speak.  That was number one.

Aaron:  When I was younger, like when I learned to speak, I was doing the CHEO program. My parents helped get through it all, like to learn to speak and everything and they never gave up.  They kept working at it and everything, especially in elementary school they always made sure I did all my work.  But now they pretty much leave it up to me since they know I can look after myself.

Facilitator:  Ok, so you are taking us right back to the beginning.  So now they basically figure you are on your own, you can handle it.

Aaron:  Pretty much.

Facilitator:  Tony?

Tony:  I’m thankful that my mom worked with me everyday cause they didn’t find out I was deaf till I was close to my second birthday.  She worked with me endless hours every day.  I remember she used to put words like pencil on the door so I would walk around the house and I would see that.  I just remember she worked till I was about seven or so, just worked every day.  And I was so thankful for that ‘cause I got kind of a late start and I’m on time.  I’m not behind a grade or anything.

In later years, individual characteristics of students with hearing loss became important facilitators of inclusion.  Such characteristics included the ability to be independent, organized, proactive, determined to succeed and enthusiastic about learning.  Students themselves mentioned the importance of keeping up with their school work, planning and reading ahead in order to be prepared for new topics and new vocabulary and requesting help from parents, teachers or peers as necessary.  These qualities were recognized as being related to the individual personality of the student but were nevertheless perceived by all groups as important to effective inclusion for the student with hearing loss. 

Lynn: Sometimes, we get children who are deaf, who have a difficult personality, and then when they don’t make friends, it’s attributed to the hearing impairment, when you wonder if they had been normally hearing, would they have had friends anyway? Just because they’re doing things maybe that make them not liked by other children.  I also put extroverts under more supportive.

Patty: I think that a naturally extroverted person would probably be easier...and the introverted person probably harder just because the introversion and the communication issue kind of feed off each other.

Marie: I had personality as the first one, and then I had children that are willing to make a real effort, you know they’re really trying, you know they’re working hard, even if they’re not successful.

Lynn: You mean like enthusiasm?

Marie: Yeah, but just that you know the kid is not just saying  "Oops, I can’t do it."  You know.

Patty: Yeah, I had attitudes as well, in terms of personality.   They go the extra mile, and the teacher will go the extra mile.

The ability to advocate for their own needs, to engage in problem-solving strategies and to take responsibility for their own learning were also perceived as personal qualities essential to effective learning in the mainstream.  In addition, students who were outgoing, had a sense of humor and were open to discussing and explaining their hearing loss to others were seen as students who would be likely to succeed in an integrated setting, especially with respect to the development of peer relationships and opportunities for social interaction.  As one of the students stated:

Tracy: One thing for me as a positive to inclusion that took place was to talk about my hearing impairment in front of the class.  Just to introduce myself and say "Hi.  I’m Tracy and I have a hearing impairment."

Jennie: Also, another thing is, and I don’t know if this is going to sound right, but my friends or friends that I hang out with and myself included, we’re not politically correct, so they constantly make jokes about me being deaf and I don’t care.  Like I  indulge them.  I make them too, so it’s not like I’m mad.  One of my friends has a sixth toe so we bother her about it all the time, so it sort of gives you a better attitude.  It makes you tons less self conscious about it.  Constantly when everybody is discussing stuff, I pick out a word and I figure that’s what they’re talking about and I am totally wrong and everybody laughs at me.  So stuff like that, just having people who are willing to make a joke out of it.

Facilitator: OK, so being really comfortable.

Jennie: Yes.  Like being willing to embarrass yourself is very important.

Barriers to inclusion within the school setting related to the students with hearing loss themselves were shyness and a lack of assertiveness in the school setting.  Although shyness itself was not considered a negative characteristic in and of itself, the negative consequences of shyness (which included an unwillingness to express their needs to teachers, peers and administrators), an unwillingness to participate in school activities and events leading to social isolation, were perceived as posing obstacles to inclusion.

As previously mentioned, all participants considered attendance at the community school as an important facilitator to inclusion.  Nevertheless, an important consequence of this was the potential lack of exposure to other students with hearing loss in the school setting, which was perceived as a potential disadvantage of the integrated environment, as demonstrated by the itinerant teachers in the following excerpt. 

Patty:   I think, supportive of the deaf child, I put down hearing-impaired peer contact. The idea that, while they’re going through school, they also have hearing-impaired friends or hearing impaired contacts.

Lynn:  Yeah, it’s fostering the same thing, the idea that hearing impairment is a normal thing, you’re not an anomaly.

Patty:  Yeah, that’s right.

Marie:  So VOICE is very good for that.  (VOICE is a charitable organization recognized as one of the largest parent-support organizations for families of children with hearing loss in Canada.)

Patty:  Yeah, yeah.  The VOICE program...some of it is more informal peer contact, but also the group activities.  We had this picnic going on for a while at school, and I think the social contact and the social activities have been tremendously helpful in making them feel normal within a larger group, they’re a subgroup of normality, but when they get together, there’s enough of them to be a powerful entity.  So I think that those social activities, that’s a good thing.

Discussion

Promoting Partnerships to Facilitate School Inclusion  

The goal of the qualitative component of this study was to examine perceptions of the facilitators and barriers to inclusion among three groups of stakeholders: students with hearing loss who had participated in an Auditory-Verbal therapy program at CHEO as preschoolers, their parents and their itinerant teachers.  The facilitators and barriers described in this article were associated with school inclusion and were related to teachers and administrators, parents, peers and students with hearing loss.   An overall summary of the facilitators of inclusion identified in the study is presented in Table 1.

Eriks-Brophy Table 1

Itinerant teachers were first in order of importance in facilitating inclusion.  These specialized teachers were perceived by all participants as instrumental in the development of the speech, language and academic skills underlying successful inclusion.  Additional responsibilities of itinerant teachers included the sensitization of teachers, peers and administrators to the effects of hearing loss.  Teachers and school administrators who fostered a team approach to meeting the needs of students with hearing loss, who were knowledgeable about the needs of integrated students with hearing loss and who used adaptive teaching strategies were also perceived as being critical to successful inclusion.  Ensuring consistency in services provided and the availability and use of assistive devices and technology were also particularly important to ensuring effective inclusion for students with hearing loss.

Parents were effective facilitators of inclusion when they became actively involved in their child’s education and were able to advocate for their child in the school setting. Characteristics of parents that were associated with successful inclusion were those parents who maintained regular communication with the teachers and school administration, who were able to devote time to volunteering in the school and following through on class assignments and who were knowledgeable about administrative policies. 

Peers in the school setting who were sensitive to the communication needs of the student with hearing loss, who could anticipate difficult communication situations and fill in gaps in information and who accepted and included their peers with hearing loss had an important facilitative role in the inclusion process.  These peers understood the perspective of the individual with hearing loss without placing excessive emphasis on the hearing difficulty.

Finally, characteristics that individuals with hearing loss felt facilitated inclusion included well-developed speech and language skills, the ability to advocate for their own needs within the school setting and assuming responsibility for their own learning. Students who accepted their hearing loss and were willing to educate others about its consequences while maintaining a sense of humor in difficult situations were perceived as being more likely to succeed in the integrated setting.  The use of assistive technology and other communication aids as necessary and the proper maintenance of these assistive devices were also associated with success in the mainstream.

Although all participants were unanimous in recognizing that inclusion was essentially a positive experience and had enormous benefits for individuals with hearing loss, they nevertheless identified numerous factors related to the school setting that could be changed to improve the inclusion experience.  The facilitators and barriers to inclusion identified through the focus groups were often described by participants as existing along a single dimension, such that facilitators that were not available or not suited to the needs of the individual student were perceived as barriers.  Students with hearing loss in particular emphasized the importance of soliciting their input related to potential facilitators and barriers to their inclusion experience and respecting their opinions and decisions regarding technology and course choices as they became older and more mature.  Overemphasis on the hearing loss leading to coddling, underexpectations of achievement and the setting of limits were particularly emphasized as unhelpful attitudes by all participants.

Findings of the study are reminiscent in many ways to those reported by Luckner and Muir (2001).  These researchers also used a qualitative approach to examine factors perceived to contribute to the success of deaf and hard of hearing students in general education settings.  Participants in their study used a variety of communication options including sign language and speech and ranged in age from 12 to 19 years.  Factors contributing to success in the schools and the wider social context fell along similar lines to those described in the present study and were associated with the students themselves, teachers of the deaf and other experienced paraprofessionals, their regular classroom teachers and their parents.  The participants were younger than those included in the present study and included a wider range of modes of communication.  The findings nevertheless highlight similar facilitators and barriers to successful education of children and youth with hearing loss enrolled in inclusive classroom contexts and provide ecological validity to the present findings.

The findings of this research support the notion that successful inclusion requires commitment from numerous sources.  Simple placement of a child with hearing loss in an inclusive environment is insufficient for achieving successful inclusion.  The provision of adequate support systems of students, teachers and parents is an essential component of inclusion.  Inclusion is facilitated when there is a partnership between knowledgeable families, professionals and children.  Key stakeholders in the inclusion process include the child with hearing loss, the family, the itinerant teacher, the school administration, the classroom teacher and peers with typical hearing. A continuum of services from early inclusion to the inclusion of children with hearing loss in their schools and communities is required in order that inclusion might be a successful experience. 

Findings from the research clearly indicate that students with hearing loss themselves cannot be held solely responsible for the success or failure of their integrated experiences.  The majority of barriers to successful inclusion identified in the focus groups were not associated with the students themselves but with the lack of knowledge, negative attitudes and insensitivity of other key players in the inclusion process.  Although all participants recognized the importance of well- developed speech and language skills for the child with hearing loss, the findings of this research emphasize the importance of examining factors external to individual children with hearing loss in preparing for their inclusion into the regular classroom.  Such variables would also be essential to the development of expanded definitions of successful inclusion and in predictions of outcome for integrated students with hearing loss. 

The research also indicates that teachers’ awareness of hearing loss and its impact on communication and learning remains an area of concern.  Although all participants were able to identify individual teachers who had been supportive of their inclusion experience, numerous  comments across groups of participants referred to teachers’ lack of preparation for teaching integrated students with hearing loss.  Teachers’ knowledge of strategies for effective teaching of children with hearing loss appears to be limited.  This has implications for educational programs preparing classroom teachers to work with integrated students with hearing loss.  It is reasonable to conclude that this lack of teacher preparation has had a direct impact on the quality of education received by children with hearing loss in integrated settings.

Although this research identified a number of important facilitators and barriers to the inclusion of children with hearing loss into educational settings, the findings are limited in their generalizability due to the demographic characteristics of the participants, the particular geographic area in which the research took place and the existence of a well-developed early intervention program and service delivery model in the region.  This model included a pediatric hospital-based preschool program, school-based resources, highly qualified itinerant teachers of the deaf and an established network of communication among itinerant teachers and families of children with hearing loss.  It would be important for future research to validate the findings in other geographical areas where other models of support and service delivery may exist.  It is likely that fewer facilitators and additional barriers to the successful inclusion of children with hearing loss would be identified in areas that do not have such well-developed support systems as those described for the Ottawa region, where the current study took place.

The findings of this research have implications for the inclusion of students with special needs other than hearing loss.  Many of the facilitators and barriers identified by the focus-group participants would likely be applicable to integrated children with other challenging conditions as well.  Examining these factors using a similar research methodology would provide insights into those areas in which schools might develop global policies and provide in-service education to teachers and peers interacting with integrated children with a wide variety of special needs.

Source: The Volta Review, 2006