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PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS
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LEARNING DISABILITIES
ASSESSMENT, MANAGEMENT AND
CHALLENGES
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PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS
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LEARNING DISABILITIES
ASSESSMENT, MANAGEMENT AND
CHALLENGES
RODNEY PARSONS
EDITOR
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CONTENTS
Preface vii
Chapter 1 The Nosological Status of
Developmental Dyscalculia 1
Júlia Beatriz Lopes Silva, Ricardo Moura and
Vitor Geraldi Haase
Chapter 2 Metacognition and Learning Disabilities in
Higher Education 25
Lucia Rodríguez-Málaga, Rebeca Cerezo and
Celestino Rodríguez
Chapter 3 Hearing Loss and Intellectual Disabilities 61
Siobhán Brennan and Sarah Bent
Chapter 4 “I Will Make a Difference”; Using the 5As Model to
Improve Issues for Adults with Learning Disabilities
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vi Contents
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PREFACE
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viii Rodney Parsons
and this may also lead to difficulties in social life in adulthood. Research
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Preface ix
different disciplines and also as a starting point for those new to the audiology
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profession. Various points on the Audiological care pathway for people with
intellectual disabilities are presented including: identification of individuals
who require hearing loss investigation, methods of assessment of hearing loss,
and appropriate rehabilitation. This chapter includes the challenges faced by
PwID and hearing loss and by clinicians. The chapter will conclude with some
of the authors’ recommendations for improved Audiological care for PwID.
Chapter 4 - This chapter details a piece of original qualitative research,
designed to improve audiological issues for adults with learning disabilities
and hearing loss who are supported by paid caregivers. The research study
comprised of four action research cycles. The first cycle involved visiting and
interviewing paid caregivers in their workplace to explore their baseline
knowledge and experience of hearing loss and hearing aids. Findings indicated
that the majority of participants underestimated the prevalence of hearing loss
and had inaccurate knowledge regarding assessment and hearing aids.
Symbolic interactionism was used as a theoretical tool to account for their
perspectives.
The second cycle involved designing and piloting a training package for a
wider group of caregivers. The content and delivery of the training was
informed by suggestions from participants of cycle one and other key
stakeholders. Situated learning and experiential learning theory were the
theoretical basis for the training design. 44 individuals were trained across 6
homes and constant refinement of the training occurred throughout the pilot
phase. Early indications were positive; participants’ knowledge and
confidence increased post training and pledges were made to continue the
change process.
The third cycle was concerned with evaluation of the effectiveness of the
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x Rodney Parsons
similar manner to cycle one. Findings from this group suggested a significant
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Preface xi
and how services can be lobbied to ensure this happens. The authors discuss
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why increasing supports for this population makes sense including financial
sense. The authors explore training opportunities for carers to ensure that
time spent with family members with Learning Disability and challenging
behaviour is of good quality. The authors conclude by emphasising the
importance of providing support and training to families in order for them to
continue in their caring roles.
Chapter 7 - The percentage of youth diagnosed with disabilities is
increasing steadily, becoming an issue that the society has to deal with in a lot
of attention. Granting academic education to these young people enables them
to become productive and self-supporting. University has opened its doors to
these students, allowing them to study any subject they desire and the authors
are ready to offer all the conditions that the students need.
The intellectual capabilities of most of these students are more than
sufficient for coping with the academic environment. The most difficult task is
to teach students to achieve success. For most of them, it is the first time they
are on their own and have to cope with basic issues as shopping, handling
money, or doing laundry. The University is ready to provide a social mentor
for each student that teaches trivial everyday activities, so that the graduate
will become independent. All of these and much more is an essential part of
this fascinating program that provides the authors’ graduates with the full
capability of becoming an independent productive member of the society.
In this article the authors show the way Ariel University is dealing with
the goal of giving those students an opportunity to be a part of the society and
the academic world.
Chapter 8 - The present study examines whether and to what extent
academic institutions integrate students with high-functioning autism. In the
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past decade, it was found that academic institutions admit such students and
have also established student support systems to aid their successful
integration in academic studies, based on a belief in the principle of integrating
students from different backgrounds. This study follows several case studies
and presents findings of the situation in academic institutions. Findings
may have practical applications for the integration of students with high-
functioning autism, the development of intervention programs, and the
integration of these students in society; therefore the beliefs and attitudes of
those who play a role in these students’ integration are a key to this process.
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In: Learning Disabilities ISBN: 978-1-63485-840-3
Editor: Rodney Parsons © 2016 Nova Science Publishers, Inc.
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Chapter 1
ABSTRACT
The concept of “Specific Learning Disorder” refers to a group of
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Corresponding author: Júlia Beatriz Lopes Silva, juliablsilva@gmail.com.
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2 Júlia Beatriz Lopes Silva, Ricardo Moura and Vitor Geraldi Haase
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The Nosological Status of Developmental Dyscalculia 3
(Dirks et al., 2008, Landerl and Moll, 2010, Reigosa-Crespo et al., 2011).
The nosological status of learning disabilities has been mainly
characterized regarding their internal and external validity (Pennington, 2009).
This concept of internal validity is analogous to the internal validity
of psychological tests. In the cases of learning disabilities, evidences of
internal validity concern the diagnostic coverage, homogeneity and subtypes,
reliability of classification with different diagnostic tools, samples and
examiners and differential diagnosis. DD is a very heterogeneous disorder
(Rubinsten and Henik, 2009) which makes it difficult to support its internal
validity. Regarding reliability and replicability of diagnostics, there are scarce
data. One main reason for that is the multiplicity of diagnostic criteria and
underlying neurocognitive mechanisms related to DD.
The external validity essentially concerns the explanatory significance of
disorder. According to Pennington (2009) the possible criteria for discriminant
external validity are: prevalence, etiology, neurocognitive mechanisms,
prognosis, response to intervention and clinical relevance (Pennington, 2009).
In the following sections, we will discuss each of these topics.
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The Nosological Status of Developmental Dyscalculia 5
disability (MLD), while the 25th percentile was recommended as a more liberal
criterion to identify children with mathematical difficulties (MD). Mazzocco's
recommendations are grounded both on statistical as well as cognitive
reasons. Research has shown different statistical criteria may sample
different populations. Participants selected on a stricter criterion have a
higher probability of having persistent and stable difficulties (Mazzocco and
Myers, 2003). Mazzocco and Myers (2003) also disclosed evidence that the
probability of an inherent disorder, in a neurobiologically based core disorder
of magnitude representation, is higher in the group with persistent difficulties.
Non-persistent difficulties identified by a more liberal criterion are more prone
to exogenous influences, such as quality of cultural and educational influences.
We advocate that a uniform terminology should be employed. Mazzocco's
(2007) proposal has the advantage of reconciling neuropsychological and
developmental/educational literatures. Moreover, the system proposed by
Mazzocco (2007) also has the advantage of distinguishing between children
with different degrees of impairment in numeric and arithmetic abilities.
(Desoete, 2008, Dirks et al., 2008). DD has high comorbidity rates with
Developmental Dyslexia and Attentional Deficit Disorder (ADHD). It is also
important to note the high co-occurrence of oppositional behavioural disorders
and anxiety and low self-esteem problems (Auerbach, Gross-Tsur, Manor and
Shalev, 2008). The high comorbidity rate is a confounding factor which makes
it difficult to precisely estimate the prevalence, as well as to identify the
cognitive deficits, in each learning disability (LD) (Rubinsten and Henik,
2009). One can even question whether there is specificity at all regarding
selective deficits in each LD. The comorbidity rates between dyscalculia and
dyslexia are higher than what would be expected by chance, if both entities
were independently segregated. At the same time, the comorbidity is relatively
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The Nosological Status of Developmental Dyscalculia 7
ETIOLOGY
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The Nosological Status of Developmental Dyscalculia 9
arithmetics (Dehaene, 2009; Piazza et al., 2010), and therefore are described as
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b) Working Memory
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10 Júlia Beatriz Lopes Silva, Ricardo Moura and Vitor Geraldi Haase
Nuerk and Moeller, 2009). Fayol, Barrouilet and Renaud (1996) demonstrated
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that the number of syllables of the number dictated could account for 33% of
the variance on a number writing task and they argue that this result could be
associated to the limited capacity of working memory. The role of WM in
transcoding tasks can be thus systematized in the following steps: encoding the
number to be transcoded; monitoring the application of transcoding rules and
the production of the numeral (Lochy and Censabella, 2005).
Passolunghi and Cornoldi (2008) demonstrated that one of the
best predictors of mathematical performance was the span of Corsi Blocks,
both in the group of typically developing children as well as in the
group of children with mathematics difficulties. In a recent study, we found
that, in children with and without math difficulties, even without group
differences in working memory, there is an overloading in WM while they
are solving arithmetic word problems that can be compensated by the
use of fingers (Costa et al., 2011).
c) Phonological Processing
development of reading and increasing interest has also been directed to the
possibility that it may be a factor constraining the development of both reading
and mathematics.
An important evidence that supports this association between reading
and mathematics is the difficulties in mathematics presented by children
with dyslexia, who have deficits in their phonological processing skills
(Griffiths and Snowling, 2001; Vellutino, Fletcher, Snowling, and Scanlon,
2004). Approximately 40% of dyslexic children also have difficulties in
arithmetics (Lewis, Hitch and Walker, 1994) and the prevalence of
reading and mathematical difficulties is similar, around 4 to 7% (Landerl,
Fussenegger, Moll, and Willburger, 2009). It is assumed that the phonological
representations of dyslexic children are weak, which leads to an impairment in
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The Nosological Status of Developmental Dyscalculia 11
cognitive processes that utilize phonological codes. The finding that dyslexic
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children are impaired on tasks that require the manipulation, retrieval and
retention of phonological codes is consistent with a core deficit in representing
phonological information (Snowling, 2000; Vellutino et al., 2004). There are
alternative theories that aim to explain the difficulties presented by dyslexic
children, such as the temporal processing hypothesis (Tallal, Miller, Jenkins,
and Merzenich, 1997) and the cerebellum impairment hypothesis (Fawcett and
Nicolson, 2001; Nicolson and Fawcett, 2001), but, in general, the phonological
deficits are still the most hegemonic and accepted point of view.
“Mathematical cognition” is a more general term that encompasses verbal
(e.g., counting, arithmetic fact retrieval) and nonverbal domains (e.g.,
subtizing, nonsymbolic magnitude comparison) (Simmons and Singleton,
2008; De Smedt et al., 2010). Recent studies have focused on the influence of
phonological processing in mathematical achievement (Landerl, Bevan, and
Butterworth, 2004; Simmons and Singleton, 2008; Landerl, Fussenegger,
Moll, and Willburger, 2009) and it is hypothesized that phonological
processing may be more strongly connected to the aspects of mathematics that
involve verbal codes as well as Arabic number representations.
Simmons, Singleton and Horne (2008) reported that phonological
awareness (by means of a rhyming task) measured at 5 years of age
predicted arithmetic and reading attainment one year after. Similarly, Leather
and Henry (1994) also reported that 31% of the variance in 7-year-old
children’s arithmetic performance could be explained by a composite score of
phonological awareness tasks.
Hecht, Torgesen, Wagner and Rashotte (2001) investigated the influence
of these subcomponents in a longitudinal study with children from 7 to 11
years old. They concluded that phonological processing skills measured on
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2nd grade strongly predicted mathematical outcomes in 5th grade even when
controlling for the autoregressor effect of prior math ability. Moreover,
phonemic awareness was the only subcomponent that influenced mathematical
outcome growth on 3rd and 4th grade. According to the authors, the influence
of phonological short-term memory and rate of access may be limited to the
second- to the third- grade time interval.
Some authors claim that the influence of phonological processing in
arithmetic could be due to shared demands with working memory, since these
effects can be eliminated when partialling out the influence of working
memory (Swanson and Sachse-Lee, 2001; Swanson, 2004). It is important to
notice that the relationship between working memory and phonological
processing could vary according to the instruments used.
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12 Júlia Beatriz Lopes Silva, Ricardo Moura and Vitor Geraldi Haase
d) Visuospatial Processing
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The Nosological Status of Developmental Dyscalculia 13
PROGNOSIS
Some of the reasons why dyscalculia deserves the status of a valid
nosological entity are the persistence of the difficulties and the high potential
to hamper academic and professional life, as well as psychosocial adjustment
(Parsons and Bynner, 1997, 2005). In a long-term perspective, considering
periods from 5 to 10 years, the probability that a diagnosis of dyscalculia will
persist is above 70% (Shalev, Manor, and Gross-Tsur, 2005).
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INTERVENTION
The relations between core numerical abilities and mathematics
achievement, as well as its involvement in DD occurrence, have been well
established over the last years (Butterworth, Varma and Laurillard, 2011;
Landerl, Bevan and Butterworth, 2004; Landerl, Fussenegger, Moll and
Willburger, 2009; Halberda, Mazzocco and Feigenson, 2008; Mazzocco,
Feigenson and Halberda, 2011; Mussolin, Mejias and Noel, 2010; Piazza et al.,
2010). It has been argued that an appropriate training of basic abilities would
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14 Júlia Beatriz Lopes Silva, Ricardo Moura and Vitor Geraldi Haase
tasks. Main inspiration comes from dyslexia research, which showed that
specific training on the core process of phonological awareness improves
general performance on more high-level abilities (for an example, see:
Torgesen, et al., 2001).
One of the first contributions regarding number sense training effects was
given by Dehaene and his collaborators with the software Number Race, a
computer game developed to work as a training tool for children with low
arithmetic performance (Wilson, Dehaene, et al., 2006; Wilson, Revkin,
Cohen, Cohen, and Dehaene, 2006). In a playful environment, children
compete against the computer on a variety of early arithmetic aspects, like
comparing numbers and set of dots (choose the larger), counting, linking
symbols to concrete quantities, and simple calculation. Their first results
indicated a significant improvement in performance on the more basic
numerical cognition tasks, like number estimation and comparison, and also on
subtraction, after the training period (Wilson et al., 2006). In the same line,
Wang, Odic, Halberda and Feigenson (in press) showed that increase in ANS
acuity is accompanied by improvement in symbolic mathematics scores.
Other results come from studies conducted by Siegler and coworkers
(Ramani and Siegler, 2008; Siegler and Ramani, 2008, 2009), who described
how other training software works on preschoolers. Their program is based on
the strengthening of number-space relationship representations by means of
classical numerical board games. According to their results, numerical board
games practice is capable to improve performance on numerical magnitude
measures and, therefore, reduce individual differences between preschoolers
on those abilities. Children with lower performance on numerical knowledge
tasks exhibited, after the training epoch, performance levels similar to that of
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The Nosological Status of Developmental Dyscalculia 15
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16 Júlia Beatriz Lopes Silva, Ricardo Moura and Vitor Geraldi Haase
current numerical performance, and also has a long term effect on later
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mathematical learning.
CONCLUSION
Even though the increase in research focusing on numerical processing is
quite recent, it already has an important impact on the clinical and educational
field, especially concerning diagnostic criteria and, consequently, intervention.
In the last decades, with the development of cognitive-neuropsychological and
neurocognitive models, the assessment of mathematical skills has become
more common. This has lead to a debate on the behavioural and neurogenetic
aspects of DD and many research methods have been used to investigate these
questions. In summary, in spite of the fact the research on DD is on the
beginning stage, there is enough evidence that supports it can be defined as a
valid nosological entity, with specific diagnostic, prevalence and etiological
characteristics.
The most imperative research questions concern the definition of the
associated neurocognitive mechanisms, as well as the development of efficient
diagnostic and intervention strategies. The elucidation of the underlying
mechanisms of mathematical processing will contribute to the comprehension
of DD. It will also support the validity of the syndrome from the
clinical epidemiological point of view, as well as the development of
consensual diagnostic criteria for its detection in clinical and educational
contexts. Although fragmentary, current knowledge allows risking some
recommendations. From the clinical-epidemiological point of view, uniformly
consistent diagnostic criteria are desirable and detailed characterization
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The Nosological Status of Developmental Dyscalculia 17
REFERENCES
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Alarcón, M., DeFries, J., Light, J. and Pennington, B. (1997). A twin study of
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Costa, A. J., Silva, J.B.L., Chagas, P.P., Krinzinger, H., Lonneman, J.,
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The Nosological Status of Developmental Dyscalculia 21
142-155.
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Moura, R., Wood, G., Pinheiro-Chagas, P., Lonnemann, J., Krinzinger, H.,
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2859-2865.
Rourke, B. P. (1993). Arithmetic disabilities, specific and otherwise: a
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Hayman-Abello, S. E. and Warriner, E. M. (2002). Child clinical/pediatric
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Gross-Tsur, V. (2001). Developmental dyscalculia is a familial learning
permitted under U.S. or applicable copyright law.
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In: Learning Disabilities ISBN: 978-1-63485-840-3
Editor: Rodney Parsons © 2016 Nova Science Publishers, Inc.
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Chapter 2
ABSTRACT
Educational research has noted metacognition as a necessary skill for
the development of an independent, constructive and meaningful learning
(Bustingorry and Mora, 2008; Conley, 2008; Pintrich and Zusho, 2002;
Pintrich, 2004), and determinant in academic success or failure of
students (Coutinho, 2007; Young and Fry, 2008). In the same way,
permitted under U.S. or applicable copyright law.
*
Corresponding author: Rebeca Cerezo. University of Oviedo. Department of Psychology. Plaza
Feijoo s/n, 33003, Oviedo, Spain. Telephone. +34-985109543; Fax: +34-985104144. Email:
cerezorebeca@uniovi.es.
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26 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
“Of all the possible knowledge, the wisest and most useful is self-
knowledge.”
William Shakespeare
INTRODUCTION
The human being is developing his abilities, acquiring new knowledges,
skills, habits, ideals, etc. throughout all his lifetime, and is, in overall, subject
of learning. Moreover, such learning enables to successfully adapt to an
“information society, of the multiple, uncertain knowledge and progressive
learning” (Pozo and Mateos, 2009, p. 54). It is beyond doubt that, among
the learning subject and the demanding society, the university plays an
exceptional role, since it can and must educate the subject, student and future
professional as an effective apprentice, able to autonomously and permanently
adapt to this reality on continuous renovation, that is, “learn to learn” (García
permitted under U.S. or applicable copyright law.
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Metacognition and Learning Disabilities in Higher Education 27
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28 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
they ease the codification and connexion between the previous knowledges
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and the new ones, as well as its record for later use (Gonzalez and Tourón,
1992; Monereo, 1990). The learning on the strategy is not only declarative
(know that strategies exist) but also how must they be employed (procedural
knowledge) and under what conditions (conditional knowledge) (Bustingorry
and Mora, 2008; Pintrich, 2000). That is, what strategies are the best suited or
suitable in relation to the task and posed objectives (Valle, Cabanach,
González, and Suárez, 1998).
In order to improve the affinity between the aforementioned concepts, we
will illustrate the following example: Let us suppose that some student takes
an exam in two weeks. He knows that he must study during the afternoons
because at night tends to the tiredness (intra-knowledge), in difference to his
mate, who focuses better during night (inter-knowledge). If he is conscious
whether his personal notes taken during the lectures are incomplete and
will not enough to pass the exam (task knowledge), he may opt to search
bibliography and to make sketches and summaries, in order to acquire a
greater understanding of the subject (knowledge of the strategy).
Therefore, the first building block of the metacognition is the
metacognitive knowledge. But besides, there would be a second block, which
is given by the metacognitive strategies. In the words of Baker and Brown
(1984):
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Metacognition and Learning Disabilities in Higher Education 29
feelings which have a fundamental rol, for they allow the student to activate,
review or establish new objectives or strategies (Efklides, 2008, 2011; Flavell,
1979). Altogether is what has been referred to “metacognitive experience”.
This can be seen in four ways and in different moments (Pintrich, 2000, 2004):
at the beginning of the activity in the shape of an ease of learning judgments
(EOL), namely, judgements around the previous knowledge to the task
(efficiency in the past and previous analogous experiences); during the
learning, in the shape of judgments of learning (JOL) when for example, the
subject feels that he has not understood what he just read or, otherwise,
when he feels satisfied with the outcome; or in the shape of feeling of
knowledge (FOK) which, as its own name suggests, alludes to the sensation of
having knowledge about something, but being unable to remember it, a
phenomenon commonly referred as the “tip of the tongue”. Finally, the
Confidence Judgments or capacity, after performing some activity, to predict
the effectiveness.
Each one of the blocks that constitute the metacognitive activity is
represented in Figure 1.
Therefore, and to summarize up, we can affirm that the learning action,
that is, to grasp, integrate and apply all knowledges in an effective way,
contemplates a level jump (Efklides, 2008; Suengas y González-Marqués,
1993), making difference between cognition and metacognition and, in
consequence, between cognitive and metacognitive strategies. As affirm
Flavel (1979) “Cognitive strategies are invoked to make cognitive progress,
metacognitive strategies to monitor it”. (p. 909). To Gargallo (2009), we can
regard two levels: higher level or metacognitive, and lower level or cognitive.
Both will be coordinated and constantly feedbacked in the sense that the
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cognitive strategies will follow the direction and orientation given by the
metacognition, i.e., the object of metacognition will the review and control on
the cognitive activity. In words of Alvares and Klimenko (2009):
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30 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
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METACOGNITIV
METACOGNITIV
E STRATEGIES
E KNOWLEDGE
Planning
Person
Monitorig
Task
Revising
Strategy
Evaluation
METACOGNITIVE
EXPERIENCES
EOL JOL FOK
Confidence Judgments
Self-Regulated Learning
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Metacognition and Learning Disabilities in Higher Education 31
their learning and then attempt to monitor, regulate, and control their
cognition, motivation, and behavior, guided and constrained by their
goals and the contextual features in the environment. These self-regu-
latory activities can mediate the relationships between individuals and the
context, and their overall achievement. (p. 253).
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32 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
planning and design the objectives to achieve. The perception of the task
would activate the set of the self metacognitive knowledges (about the general
working) and about the activity in particular (cognition area) as well as the
previous experiences, the first judgements on the task (metacognitive
experience) along the expectations and utility assessments (motivation area).
Also will take place the first estimations on the time or effort needed
(behavioral area) and the assessment on the environment organization and the
study place, in order to obtain the previous objectives (context area).
Straightaway and immersed in the learning, the metacognitive consciousness,
perception of the motivational mood, along the self-observation of the
behavior and the context (suitable management of time, need of assistance)
will be crucial to pick and/or modify the cognitive and motivational strategies,
as well as to initiate changes in the attitude (increase or decrease of the effort,
change or abandon of the context, etc.). Among all the results of this process
(success or fail), the apprentice will generate an assessment or causal
attribution (Valle, Rodríguez, Cabanach, Núñez, and González-Pienda, 2007),
and future behavior (election or not of the same set of strategies).
Therefore, according to Nuñez (2009) “to learn something new it is
needed to dispose the capacities, knowledges, strategies and skills to -can- and
have the enough mood, intention and motivation to -want- for achieving and
conquering the intended goals” (p. 41). In words of Zimrneman (1989) “we
will speak of a self-regulated apprentice in the way that he is compromised in
a metacognitive way, motivationally and in behavior to his own learning
process” (p. 329).
permitted under U.S. or applicable copyright law.
In the last few years, the study of the self-regulated learning and in
particular metacognition, has attained to become a key theme and of the
greatest importance for educators (Azevedo and Aleven, 2013; Garcí Martín,
2012; Montalvo and Torres, 2004; Núñez, Solano, González-Pienda and
Rosario, 2006; Rosario et al., 2014). In this sense, the results from the research
have pointed out as the use of metacognitive strategies as an essential factor
for the quality of the apprentices on pair of differential and explicative of the
students success or fail (Lamas Rojas, 2008; Zimmerman, 2002). For instance,
Pérez, Castellanos, Díaz, González-Pienda and Núñez (2013) analyzed in a
sample of university students the connections among the adoption of a deep
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Metacognition and Learning Disabilities in Higher Education 33
(p. 53).
The study of metacognition not only has been linked to the performance,
but also with affective/emotive aspects. In this sense, some studies have
established mutual relationships and influences between metacognition, mood
and motivation, with important effects on learning (Efklides 2011; Palladino,
Poli, Masi and Marcheschi, 2010). The correlation between self-efficacy and
metacognition has also been object of research. Thus for example, in the study
of Coutinho (2008), it was found that the students who employed effective
metacognitive strategies also had a strong believe on their own work capacities
to carry out a given task (self-efficacy).
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Metacognition and Learning Disabilities in Higher Education 35
In the same line, the Individuals with Disabilities Education Act (IDEA)
define them as:
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Metacognition and Learning Disabilities in Higher Education 37
respect to the distinctive features that compound the rank of specific learning
disability, can be understood in both ways (Ortiz González, 2004): inter-
individual, namely, the difficulties are manifested in different ways among the
individuals that share such condition, and inter-individual: differences in the
same subject, either when comparing diverse areas, or given by function of the
developing stage.
According to the definition from the el National Joint Committee
on Learning Disabilities, another existing problem in people with learning
disabilities is a shortfall in the self-regulated behavior: “problems in self-
regulatory behaviors, social perception, and social interaction may exist with
learning disabilities but do not, by themselves, constitute a learning disability”
(NJCLD, 1994, p. 45)
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38 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
disabilities starts already in the 80’s, when some authors, as Torgensen (1977)
or Swanson (1990) posed the possibility of explaining the problems of this
collective as a result of the ineffective developing of the metacognitive
strategies. Ever since, educational and cognitive psychologies were concerned
on delving the study and its relation between metacognition and learning
disabilities. Consequently with the traditional literature, some studies carried
out in adolescents (Pintrich 1994) seem to confirm the differences in the
metacognition capacities between subjects with and without SLD. Currently, it
has been defined these subjects as inactive learners (Romero and Cerván,
2005), when adopting a cognitive behavior, lacking of motivation and for
suitable learning strategies, adapted to the content (Bravo Valdivieso 1994). It
seems that such differences would not be only at a general level (Hen y
Goroshit, 2012; Palladino, Poli, Masi and Marcheschi, 2010) but specific,
namely, related to the learning disabilities. Thus for instance Garrett,
Mazzocco and Baker (2006) examined the metacognitive skills, or more
precisely, the metacognitive experience (through the confidence judgements)
in a sample of children with (n = 17) and without (n = 179) specific learning
disabilities in mathematics during troubleshooting. The authors concluded that
children with disabilities where less accurate on their judgements and
assessments about the (in)correct answers.
ADHD has come to form part of the diagnostic category labeled
as disorder by attention deficit and disturbing behavior (DSM-IV-TR, APA
2001) together with the DEA under the condition “neurological disorder of
developing” in the DSM-V(APA, 2013), alluding thus to an intrinsic neuro-
psychological origin, far from a contextual approach (Casas, Herrero and
Ferrer 2015). Following the DSM-V we quickly comment some of the most
permitted under U.S. or applicable copyright law.
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Metacognition and Learning Disabilities in Higher Education 39
50% of the children with the disorder will continue to have it as adults” (p.
600). The authors also point out a light difference in youngsters, which is a
lesser hyperactivity and impulsiveness, but with the same attention disorders.
Moreover, it seems to exist some agreement in authors when referring to the
performance dysfunction as the chief deficit and reflex, not only of the control
of the inhibitory problems in behavior (Shuck and Crinella, 2005; Wasserstein
and Lynn, 2001), but also the metacognitive problems associated to such
disorder (Romero-Ayuso, Maestú, González-Marqués, Romo-Barrientos and
Andrade, 2006). Thus for instance, Barkley (2010) stresses the importance of
the comprehension of the metacognitive function in the ADHD as possible
differential barrier to other disorders that share similar features. Cognitive
deficiencies in ADHD, and as equal as the SLD, seem to be manifested in the
development of strategies (deficit in the troubleshooting) and incapacity to
plan and handle self-behavior, namely, metacognitive deficiencies (Barceló,
2005).
also in the lack of interventions to help them with a visible scientific basis
(Gerber, 2012; Floyd, 2012; Gregg, 2012). Currently, as Ortiz Gonzalez
(2004) suggests, most of the interventions are focused on primary school and
on the handling of the most basic learnings (reading, writing, mathematics).
It is not surprising therefore that the skills to learn and acquire new
knowledges, as well as to successfully and consciously use them were not
fully deployed when arriving at higher school, being a cause of a low
performance (Pérez, Castellanos, Díaz, González-Pienda and Núñez, 2013),
complete fewer academic credits (Bergey, Deacon and Parrila, 2015; Murray
Goldstein, Nourse and Edgar 2000) and even a dropout rate up to two to
three times higher (Taymans, 2012). In fact, it can be founded some
agreement among the authors that strengthens the lack of skills and academic
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40 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
Method
Results
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In overall it has been selected 8 articles. Only those whose main subject
was the study of metacognition in undergraduate students with learning
disabilities within the last 10 years. To record and organize it has been made
a table with the following fields: source (authors, publishing year), sort of
study (research methodology), sample (number of participants) and aspects
addressed in the research (Table 2).
In order to shed some light on this topic we will now detail each one of the
studies that have been found and their main achievements and conclusions.
Trainin and Swanson (2005) attempted to observe if students with learning
disabilities compensate their deficits of phonological processing by leaning on
metacognition? and, if the use of metacognitive strategies or metacognitive
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Metacognition and Learning Disabilities in Higher Education 41
control a key to the success of these students. For that purpose, the authors
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compared both the reading capacity as in the learning strategies through the
questionnaire LASSI, as well as the learning approach (measured with the
questionnaire SPQ-R). The results confirmed the disabilities in the reading
process in subjects with dyslexia. It was also found a strategic profile different
in both parties: In a difference with respect to the control party, the dyslexic
subjects shown a weaker result on the choice of the main idea and the
strategies followed when taking exams. On the contrary, the use of assistances
for study, time management and adoption of a deeply-rooted learning
approach appeared to be the strongest points of this party. To the authors, the
metacognitive behavior of this class could move on in two directions: positive
and negative. Negative: The learning disabilities in the reading process would
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42 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
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Furnes and Norman (2015) starting from the set of ideas exposed by Kirby
(2009) and in the aim obtain a greater information about the relation between
metacognition and dyslexia decided, by means of a reading test, to rate the
three components of metacognition: knowledge, strategies and experience.
They used a sample consisting of 44 undergraduate students from ten dutch
universities that were divided into two groups: experimental, subjects
previously diagnosed during primary and secondary school (n = 22) and
control group (n = 22). For the evaluation of the knowledge and metacognitive
strategies the employed two questionnaires of self-report. The metacognitive
experience was assessed by the capacity of the subjects to predict their
performance through the learning judgements. They used two textbooks, for
each of them, they took two measures: one after 5 minutes (at the middle of
the text) and other one at 10 minutes (at the ending) where they were asked
through a Likert scake (four choices: from less probable to very probable) to
indicate the number of questions they thought they would be able to answer
(referred to the part of the text they have just read). The authors found that
both groups had the same level of performance on each of the metacognition
components and, perhaps, such performance analogous was being some reflex
of compensation.
Chevalier, Parrila, Krista and Deacon (2015) examined in a sample of 372
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44 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
students with HDR (history of reading difficulties) would have a lower marks
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average, would inform a lower use of the metacognitive reading, learning, and
study strategies but more behavioral study and learning strategies than students
without HRD. Consequently to what was expected, the results revealed lower
marks in the experimental group. Furthermore, the variance analysis revealed
that the HDR group had lower levels of specific metacognitive strategies (of
reading) and learning strategies (cognitive and metacognitive). The results of
the multiple regression shown that, for the students with HRD the use of
strategies (metacognitive and cognitive) was associated to higher levels of
academic performance. The authors concluded that the use of metacognitive
strategies was a nice predictor for the academic success for the students with
HRD and also pointed out that, the measurements of self-inform employed
could be useful to identify the groups of students potentially at risk of low
academic performance.
In the same line, Bergey, Deacon and Parrila (2015) attempted to
determine the presence of differences among the students with and without
precedents of reading disabilities (HRD = 244; NHRD = 603 respectively) in
the use of metacognitive strategies of reading, cognitive and metacognitive
strategies (measured by the MRSO -A and LASSI). They also examined the
relation between the adoption of strategies and academic performance. In
comparison to their peers, HRD obtained lower marks on the two measures of
strategic behavior: their overall average marks was also lower. Nevertheless
and, in difference with the previous study, no significant correlations between
the use of strategies and academic performance (GPA) were found. The
authors concluded that the HRD subjects could be employing unique strategies
or not regarded in teh LASSI and MRSO-A which might be the explanation
for such performance.
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Metacognition and Learning Disabilities in Higher Education 45
They found that the students with dyslexia were as good as their peers
when casting confidence judgments. They only had more cases where their
orthography was wrong. The authors confirmed that persons with dyslexia
would not suffer twice (double load) as the result of the insufficient
developing of the metacognitive competences.
Reaser, Prevatt, Petscher and Proctor (2007) compared the learning
strategies in students with ADHD, SLD (13 percent dyslexia, 25 percent
dyscalculia, 32 percent dysgraphy and 30 percent of the subjects with a
mixture of more than one difficulty) and without any kind of difficulty. They
tried to know further, if such strategies could predict the subjects academic
success. 150 students participated, divided into two groups: experimental
(SLD and ADHD, n = 100) and control (n = 50). They used the LASSI scale
as measure. The results drawn from the regression analysis revealed
differences with the control group and among the subjects that conformed the
experimental group. With respect to the first ones, the two areas where the
ADHD and SLD made with less effectiveness than in the control group where:
Information Processing and Self-Testing. A low mark on these scales
would mean a problem when, not only managing the information in order
to successfully process it, but also in the capacity of reviewing the
comprehension and development
With respect to the second ones, ADHD informed about the lowest marks
than SLD in: Time Management, Concentration, Selecting Main Ideas, and
Test Strategies. Seemed thus to present greater difficulties to employ effective
strategies in time management, lower attendance capacity, isolate the relevant
information from the whole content as well as to set the study to the kind of
exam. On the contrary, the SLD group obtained higher scores than the ADHD
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(or even than the control group) in the scale of assistances to the study.
However, only the motivation was a strong predictor from GPA.
The authors emphasized on the one hand, the relevancy of the
deterioration of the metacognitive and self-regulated behaviors (lowest marks
in all the measures related to the strategic learning) and on the other hand, the
differences found among TDAH and SLD when providing for suitable actions
to the referred disability or disorder, as well as to the affected areas.
Hall and Webster (2008), unlike their previous colleagues, attempted to
see in a 55 students sample, possible differences around: metacognitive
capacity, affective factors (resiliency, self-efficacy, locus of control, and need
for achievement) and GPA. The experimental group was formed by 27
students, the control group was conformed by 28 volunteer students (n=28)
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Metacognition and Learning Disabilities in Higher Education 47
MRSQ or EPQ scales. Until now, in the field of research, these questionnaires
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of the academic year, even though the literature has been evidencing the
improvement the result's robustness through a multimodal assessment and at
different time moments (Cerezo, Sánchez-Santillán, Paule, and Núñez, 2016;
Cromley and Azevedo, 2007).
CONCLUSION
Metacognition is perhaps one of the skills that contribute the most to a
quality learning (Monereo and Pozo, 2003). Inasmuch as we are aware on how
do we learn, what are our strengths or limitations, we can introduce some
degree of control on them and hence, we can improve them. Metacognition
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turns out to be a prerequisite “sine qua non” for self-regulated learning too
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Metacognition and Learning Disabilities in Higher Education 49
found, it has been proposed for future researches a more thorough analysis and
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REFERENCES
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applicable copyright law.
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In: Learning Disabilities ISBN: 978-1-63485-840-3
Editor: Rodney Parsons © 2016 Nova Science Publishers, Inc.
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Chapter 3
1
Audiology and Deafness, School of Psychological Sciences,
University of Manchester, England, UK
2
Regional Department of Neurotology,
Sheffield Teaching Hospitals, Sheffield, England, UK
3
Betsi Cadwaladr University Health Board, Wales, UK
ABSTRACT
There is a high prevalence of hearing loss in individuals with
intellectual disabilities and it can affect communication, personal
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*
Corresponding Author’s Email Address: Siobhan.brennan@manchester.ac.uk.
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62 Siobhán Brennan and Sarah Bent
hearing loss and by clinicians. The chapter will conclude with some of
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1. INTRODUCTION
Our relationship with sound is personal and unique. The impact
that hearing loss has on quality of life will vary enormously depending on
the person, but is known to potentially affect communication, education,
relationships and mental health. There is growing awareness of the importance
of hearing health in the general population internationally; however, this issue
is still under-recognised for those with intellectual disabilities. In this
population, not only is the prevalence of hearing loss greater but the impact on
life is too, particularly if not recognized; yet this is little known by those in
caring or other health roles. The authors aim to provide a summary of
the importance of hearing loss identification and rehabilitation, both for
professionals across different disciplines and as a starting point for those new
to the audiology profession.
This chapter discusses the points along the Audiological care pathway for
people with intellectual disabilities (PwID) including: identification of
individuals who require hearing loss investigation, methods of assessment of
hearing loss, and appropriate rehabilitation. This includes the challenges faced
by PwID and hearing loss and by clinicians. This is drawn from both peer-
reviewed and grey literature internationally, with additional recommendations
from the authors’ experience individually and as part of the UK special interest
group for professionals working in hearing and people with learning
disabilities, HaLD. The chapter will conclude with presentations of the
authors’ recommendations for improved Audiological care for PwID.
permitted under U.S. or applicable copyright law.
2. HEARING LOSS
According to the World Health Organization, there are currently 360
million people with disabling hearing loss globally (WHO, 2015). The
prevalence varies with country, but to take as an example the UK, hearing loss
affects approximately 1 in 6 of the population. Prevalence figures are
considerably higher in individuals with intellectual disabilities and higher still
with certain syndromes; however, there are significant limitations to this data.
This is partly related to the accuracy of hearing tests in the literature - some of
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Hearing Loss and Intellectual Disabilities 63
the adjustments that should be taken when testing hearing in this client group
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are often not available. Many authors draw prevalence data from hearing
screening programmes carried out at the Special Olympics; this data is
restricted to individuals who are usually in good physical condition and often
with milder intellectual disabilities, and so possibly not truly representative
of the population as a whole. However, Hey et al. (2014) compared the
prevalence figures from the Special Olympics with that of the residents of a
school for individuals with intellectual impairment and found the 2 sets of
prevalence data very similar.
Despite this high prevalence, hearing loss is still not widely recognised.
As an example, one study suggested 70% of adults over the age of 40
with Down Syndrome to have significant hearing loss undiagnosed before
systematic hearing testing (Van Buggenhout et al., 1999). Possible reasons for
this are discussed further below.
The leading cause of hearing loss in any population varies by country due
to factors including general health, genetics and exposure to drugs and noise.
One of the primary aims of professionals such as Audiology or Ear Nose and
Throat teams, who see individuals referred with concerns about their hearing,
is to identify what type of hearing loss they may have. The type of hearing loss
will partly determine the most appropriate management, as there are simple
surgical and medical options available for some causes. Hearing losses can be
loosely grouped into conductive hearing loss and sensori-neural hearing loss
(or a mixed loss, which means there are multiple causes for the hearing loss).
permitted under U.S. or applicable copyright law.
This section outlines some of the more common issues that are identified as
causing a hearing difficulty in both the general population and those with
intellectual disabilities.
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Hearing Loss and Intellectual Disabilities 65
western pacific and African regions, and ethnic minorities in the pacific rim.”
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that reported on hearing loss prevalence with age. The prevalence of hearing
loss in adults with intellectual disabilities under the age of 50 was found to
range from 27% to 45%, and over 50 years of age from 59% to 68%
(Buchanan, 1990; Venhuis, 1995; Evenhuis et al., 2001; Meuwese-Jongejeugd
et al., 2006; Van Buggenhout et al., 1999).
While there are multiple syndromes which feature hearing loss and an
intellectual impairment, Down Syndrome has the highest incidence of hearing
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66 Siobhán Brennan and Sarah Bent
loss. The prevalence of sensori-neural hearing loss is higher in this group from
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birth, and this incidence increases as the individual gets older. Age related
hearing loss is not only more common in Down Syndrome but also at an
earlier age, often by 20 to 30 years. Three studies looked specifically at the
prevalence of hearing loss in individuals with Down Syndrome, due to the
associated high rate of sensory issues and precocious ageing. For this specific
group under the age of 50, prevalence was reported from 38% to 76%, and for
those over 50 years of age, from 62% to 93% (Evenhuis et al., 2001;
Meuwese-Jongejeugd et al., 2006; Van Buggenhout et al., 1999).
Appropriate management will be discussed later in this chapter, but it
should be highlighted that ear wax is a particular issue for this group as ear
canals are typically narrow, so only a relatively small amount of ear wax is
sufficient to block the ears.
Additionally, for individuals with Down Syndrome, glue ear is much more
common than in the general population, due to a number of factors such as
narrower eustachian tubes and the middle ear fluid tending to be of a different
viscosity than in other people, taking longer to drain and more likely to
become infected (Sacks and Wood, 2003).
There are many syndromes which commonly present with both hearing
loss and intellectual disabilities, including Down Syndrome, CHARGE
syndrome and Cornelia de Lange. In addition to syndromic causes, there are
genetic causes of the co-morbidities of hearing loss and intellectual
disabilities, such as chromosomal and mitochondrial disorders. There are also
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a wide range of perinatal factors that can influence hearing and intellect,
including extreme prematurity and congenital infections. Some causes of
intellectual disability have specific types or patterns of hearing loss, or other
symptoms that are uncommon with other causes. It is beyond the scope of this
chapter to provide a thorough discussion of these factors.
Intellectual disabilities are usually present with multi-morbidities, some of
which will compound the impact of hearing loss and should also be taken into
account when the hearing is being assessed and managed. These are discussed
as relevant to each section.
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Hearing Loss and Intellectual Disabilities 67
Those with concerns about their hearing should seek help in order that any
pathology may be addressed, to understand what is causing the difficulties,
and to seek rehabilitation. Hearing loss which is not identified or managed can
have serious effects on communication, social activity and participation, along
with increased risk of depression and dementia (Action on Hearing Loss.,
2014). It is known that there tends to be a ten year delay in seeking help
for hearing in the general population (Davis et al., 2007); it is thought
to be worse still in those with intellectual disabilities. This may be in part
due to some carers’ lack of awareness of symptoms of hearing loss. Also, in
the case of adults with long standing undiagnosed hearing loss, if the
individual has developed an alternative form of communication that is
effective there may be a lack of interest in hearing assessment. Hearing loss
is as affected by diagnostic overshadowing as any medical condition, with
typical misconceptions being that lack of response to speech or an observed
behaviour change is related simply to a person’s intellectual disability.
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68 Siobhán Brennan and Sarah Bent
3.2. Screening
under-identify hearing loss (Bent et al., 2015). It has also been suggested of
general practitioners’ role “Current training is not sufficient to provide the
skills for detection and management of hearing problems” (McShea et al.,
2015).
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Hearing Loss and Intellectual Disabilities 69
experience and other demands on the service. While there are advantages in
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There are other services which have close relationships with audiology.
As well as the Ear, Nose and Throat team, a hearing assessment will often
have a major impact on the outcomes of Speech and Language Therapy and
Psychology. With regards to Psychology, the frequent relationship between
hearing loss and poor mental health is well established (Saito et al., 2010;
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Monzani et al., 2008; De Graaf and Bijl, 2002; Cooper, 1976). This is
frequently due to depression arising from isolation (Matthews, 2013). An
increasing amount of research suggests that there may be a correlation
between hearing loss and cognitive decline, and at the time of writing, a
growing body of work is investigating whether therefore the use of hearing
aids slows this change (e.g., Ameiva et al., 2015). For individuals with Down
Syndrome, dementia often occurs earlier than in the general population (Van
Buggenhaut et al., 1999). This, combined with the early onset of presbycusis,
can have a multiplicative impact. There are strong arguments for a hearing
assessment being a standard part of the dementia test battery, and cognition
being considered alongside hearing assessment. As a minimum, links should
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directions.
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Hearing Loss and Intellectual Disabilities 71
4. HEARING ASSESSMENT
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There are multiple aims in hearing assessment. Some of the questions the
clinician hopes to answer include “What are the quietest sounds this person
can hear?,” “Can this person discriminate sound sufficiently to understand
speech?” but fundamentally “Does this person have sufficient hearing to lead
the life they want to lead?” Different tests carried out in an Audiology clinic
can contribute to answering these questions, ideally in conjunction with the
reported experience of sound from the client or carers. The priorities for the
assessment should be established early in the clinical encounter. The hearing
assessment battery should consist of multiple tests – each test represents
different parts of the hearing pathway and there are many instances where 2
people with the same single test result can ultimately have very different
hearing capabilities. Only collectively can the assessments inform the
Audiologist about the client’s possible experience of sound. In addition to
guiding the management process the hearing assessment can also provide an
opportunity to demonstrate to both the client and their carers the presence and
extent of a hearing loss. This is particularly useful as carers reports are known
to overestimate hearing ability (Bent et al., 2015) and a proficient hearing test
provides some level of clear evidence.
This section of the chapter aims to present a range of commonly
used clinical hearing assessments, their limitations and considerations when
being used to assess hearing for PwID. Recommendations for reasonable
adjustments are then suggested that could be used to address some of the
challenges of these tests.
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72 Siobhán Brennan and Sarah Bent
be very aware that on walking toward a door it will be necessary to get ready
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without ever hearing “please put on your coat.” It may be possible to glean
information on hearing from reported reactions to different types of sound.
Being more responsive to male voices might suggest that hearing is better at
low frequencies. Enjoying some music genres more than others may suggest
that there is sufficient hearing to identify the differences. Caution should be
used when drawing conclusions on hearing capabilities based entirely on
observation – for instance the teenager who turns music up may indeed be a
sign of deteriorating hearing, but may also be due to enjoyment commonly
gained from loud music. Table 2 presents some observations that may indicate
that someone should have a hearing assessment.
Behaviour directed Puts 1 hand or both over each ear for no reason
towards ears Bangs or slaps face
Frequent touching of ears
Unusual head movements
Pulls ear lobes
Cups hand behind ear
Auditory behavior Developing behaviour that challenges
changes Unexpected changes in behaviour
Seems confused
A lack of response to specific sounds
Tends to respond more consistently to sound
presented on one side
Attention span decreasing
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The communication form that someone has chosen to use may be in part
due to an underlying hearing loss. Also, some forms of communication may
obscure signs of a progressive hearing loss – for example, with largely visual
forms of communication such as Makaton, responses to speech may not
change as dramatically as someone who relies on heard speech. While
understanding a client’s preferred form of communication is a fundamental
part of assessing the appropriate management, the reality is that audiology
clinicians with a working knowledge of communication methods such as
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Hearing Loss and Intellectual Disabilities 73
Makaton, PECS and Objects of Reference are in the minority. Music is often
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such as infection or earwax in the outer ear. It typically takes under a minute
in each ear. This is unobtrusive for many, but individuals who are tactile
defensive or dislike other people being in close proximity may find this
process uncomfortable.
While otoscopy and discussion with the client and those people closest to
them is the starting point of a hearing assessment, it is imperative that a
hearing assessment goes beyond this. Hearing can be tested in a range of ways
depending on aim of the assessment.
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74 Siobhán Brennan and Sarah Bent
4.3.1. Observation
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During the initial discussion with the client and anyone they choose to
bring to the appointment it is a good opportunity for the Audiologist to
observe the client’s ability to hear the questions being asked and their interest
in conversation. This dialogue may be affected by level of comfort with the
situation in addition to their hearing abilities. Observations can also be carried
out at home and at day services to evaluate a client’s functional hearing, that is
how someone uses their hearing.
4.3.2. Audiometry
Pure tone audiometry (PTA) is a standard hearing test to identify the
quietest sounds that the individual can hear at a range of tones (frequencies).
These levels are then compared to levels expected in those with satisfactory
hearing. The client is asked to wear headphones and respond every time they
hear a sound which will vary in volume and frequency. The response is often
pressing a button, but where there are additional physical disabilities affecting
the response, the tester should use a creative approach to enable the patient
to respond comfortably and reliably. For an individual with an intellectual
disability, there are aspects of this test that may influence its accuracy:
Responses to No Sound
The test depends on an individual’s ability to wait. In the general
population people occasionally respond when there is no sound presented.
This risk tends to be higher for individuals with intellectual disabilities. This
may be due to lack of understanding of the need to wait for the sound or the
wish to “please” the tester by relating that they have heard a sound even when
this may not be the case. There are tactics that the tester can employ to identify
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when this may occur such as lengthened and more variable gaps between
sound presentation, and lateralisation (“ear choice” audiometry (Lloyd and
Melrose, 1966)). Lateralisation in this context involves randomly changing the
ear that the sound is presented to and asking the client on which side the sound
is. For some individuals, this change of task is sufficient to improve the
accuracy of the test.
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Hearing Loss and Intellectual Disabilities 75
are instances when the stimulus frequency changes, and the patient does not
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react to this change immediately. The tester may then misread this lack of
response as a lack of hearing to this stimulus.
Dislike of Headphones
For some people headphones are unpleasant to wear, particularly those
typically used in an Audiology clinic. Presenting the sounds through a speaker
(free-field), usually a hand-held device, can address this. This has the
advantage of accompanying family or carers being able to hear the levels of
sound at which the individual can hear, and the differences across frequencies.
The major disadvantage of this method however is that because the sound is
travelling to both ears, it is not possible to be sure which ear is responding.
concerns that an asymmetric hearing loss raises, there are other disadvantages
in this type of hearing loss. While it is possible hear well with one ear, if
hearing is good in both ears it is easier to “localize,” or identify where a sound
is coming from. This has safety implications and can increase the feeling of
comfort in a range of situations. Another benefit of hearing well in both ears is
that hearing speech in background noise is improved. This is because the brain
compares the information from each ear, along with visual cues if we are able
to find the speaker and look at their faces.
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76 Siobhán Brennan and Sarah Bent
and if the client turns towards the source of the sound there is an image of
interest to encourage them to continue to turn to sounds so that a range of
volumes and frequencies can be tested. Responses to sound in this situation
can vary widely and it is imperative that the tester and someone who knows
the client well work together to interpret reactions that the client may have in
response to sound. There are some who may not make the connection between
the sound presentation and the image, however in this case the tester and
family member or carer together can observe any responses the client makes to
presented sound. Examination of the outcomes of VRA testing at a specialist
clinic over the space of a year identified that responses sufficiently reliable to
draw conclusions about hearing status were found in a third of clients for
whom VRA was used (Dubb and Brennan, 2013).
in the stimulus does not necessarily reflect the inability to hear that stimulus.
Additionally, speech tests are sometimes pre-recorded; if someone struggles to
recognize words spoken in an unfamiliar accent this can affect the accuracy of
the results.
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Hearing Loss and Intellectual Disabilities 77
are not sufficiently repeatable. The majority of these tests can be carried out on
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an outpatient basis, for which the client should be relatively still and quiet. If
this is not possible, some of these types of tests can be offered to take place
under general anesthetic; in which case there is benefit to completing on the
same occasion as any other procedures the client is to have which require a
general anesthetic.
of the body the person being tested needs to be relaxed, and can be recorded
while the person is asleep. This test is ideal for hearing assessment under
general anesthetic. This test can be frequency specific and can take anything
from 10 minutes to an hour depending on how much information is needed
and how low the background noise is.
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recording under general anesthetic. This test is also frequency specific and
again can take anything from 10 minutes to an hour depending on how much
information is needed and how low the background noise is.
5. REHABILITATION
The impact of hearing impairment on each person is different. When
considering rehabilitation, there are a large number of factors which should
be taken into account. What are the forms of communication used by the
individual? Will the use of technology, such as a hearing aid, help or hinder
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a whole, it has been found that the expectations and wishes around hearing
aids by individuals with intellectual impairment are similar to those of the
general population, including sound quality, cosmetics and comfort
(Meuwese-Jongejeugd, 2007).
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Programming the hearing aid often requires making Real Ear Measures
(REMs). This involves placing a small tube in the ear canal with the hearing
aid in place to measure the sound. Placing an identical hearing aid on 2
different ears can sound very different - imagine how different your voice
sounds in a cave to how it sounds in your living room! If a client has too much
involuntary movement or earwax to make this a safe procedure the hearing aid
can be set up in a coupler (a small tube which imitates an ear) using average
data called “Real Ear to Coupler Difference (RECD).” However, there are
syndromes associated with intellectual disabilities and hearing loss such as
Down Syndrome which present with smaller external ears than expected and
the standard RECD may be inaccurate. For these individuals, coupler fittings
may be inaccurate. How someone perceives familiar voices will be more
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Hearing Loss and Intellectual Disabilities 81
once it is established that the patients enjoys the use of the hearing aid and gets
benefit from it, should a second hearing aid be considered.
Hearing aids are becoming much better in terms of their ability to cope
with music. It should be explored at the point of assessment whether the client
has an interest in music, so that this can be taken into account in the hearing
aid fitting. This could be a stimulus that is used to develop a person’s
relationship with their hearing aid.
The uptake of hearing aids is known to be poor in individuals with
intellectual disabilities if there is insufficient provision of adequate support
and follow-up. Review appointments are to assess the outcomes of hearing aid
use after it has been worn for a time. In addition to the identification of any
logistical issues, discussions should also focus around particular parts of a
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82 Siobhán Brennan and Sarah Bent
person’s life where they found the hearing aid of benefit or that it caused
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For those clients for whom hearing aids are not wanted or appropriate,
there are still many benefits of hearing assessment. If the client and their
family or carers are aware that there is a hearing issue, a greater amount of
support can be offered and hearing tactics can be developed. Also there are a
wide range of adaptations and assistive listening devices available, such as
connecting fire alarms to the lights, or amplified telephones. The form of
communication that someone uses should be considered within the context of
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Hearing Loss and Intellectual Disabilities 83
If there is a difference between the ear moving the better ear toward
the speaker
Make the speaker aware of a hearing loss
There are many more tactics that can assist the listener with a hearing
impairment. If a client works with multiple of carers, it would be useful for all
of these carers to become familiar with them.
radio signal to the hearing aid. FM systems can be either personal FM systems
where the speaker may wear the microphone such as in a classroom setting, or
FM systems which have a fixed microphone to help in a public setting, such as
a bank or theatre. When the user has an intellectual disability care it may be
necessary for the individual or anyone supporting them to become familiar
with these devices. In some countries these devices are offered through social
care services or 3rd sector voluntary organizations. New technology is also
becoming available rapidly, including wireless and Bluetooth options for
connecting hearing aids to the client’s own personal technology such as
telephones.
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CONCLUSION
Regrettably, hearing loss is one of the many health issues that is under-
identified in individuals with intellectual disabilities. Even if suspected, the
effect of hearing loss is often underestimated or not prioritised. As
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Hearing Loss and Intellectual Disabilities 85
REFERENCES
Action on Hearing Loss (2014) Caring for older people with hearing loss
Retrieved May 2016 from file://nask.man.ac.uk/home$/Caring%20for%
20older%20people%20with%20hearing%20loss_March%202013.pdf
Action on Hearing Loss (2016). Communication Tips. Retrieved May 2016,
from www.actiononhearingloss.org.uk/your-hearing/ways-of-communicat
ing/communication-tips/tips-for-people-with-hearing-loss.aspx.
Action on Hearing Loss (n.d.). Communication Tips. Retrieved May 2016,
from www.actiononhearingloss.org.uk/your-hearing/ways-of-communicat
ing/communication-tips/tips-for-people-with-hearing-loss.aspx.
Action on Hearing Loss (n.d.). Communication Tips. Retrieved May
25th, 2016, from www.actiononhearingloss.org.uk/your-hearing/ways-of-
communicating/communication-tips/tips-for-people-with-hearing-loss.
aspx.
Balkany, T.J., Mischke, R.E., Downs, M.P. and Jafek, B.W. (1979). Ossicular
permitted under U.S. or applicable copyright law.
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