Download Unilateral Hearing Loss: Demographics and Educational Impact

Unilateral Hearing Loss: Demographics and
Educational Impact
Robert F. Oyler, Anne L. Oyler, and Noel D. Matkin
This article presents the findings of a two-fold investigation. First, the demographic distribution of unilateral hearing loss in a large school district having
approximately 54,000 students is reported. Second, the academic performance of the
unilaterally hearing-impaired students is presented. The findings suggest that a
unilateral hearing loss may have an adverse effect on some students' performance,
contrary to the conventional attitude regarding this disorder.
The conventional attitude concerning the effects of a unilateral hearing loss has
been that it would have little impact upon a child's academic performance.
Reflecting this view, Northern and Downs (1978) have stated that a child with a
unilateral hearing loss "will be able to go through school and learn just like any
other child" (p. 143). The child's parents and the child, if old enough, were
admonished to guard against trauma to the good ear and to be aware of the
difficulties the child might encounter with respect to localization and the comprehension of speech in difficult listening environments. Educational recommendations were essentially limited to preferential seating in the classroom.
An investigation by Boyd in 1974 (cited in Northern & Downs, 1978) might have
alerted professionals that the conventional attitude was in error. Boyd found that
30% of a group of children with "unilateral deafness" had an average academic lag
of more than 1 year. Unfortunately, the subject selection criteria for this study were
not presented and the study was never published. Therefore, one is left without
knowing Boyd's definition of unilateral deafness.
A more recent study involving 60 unilaterally hearing-impaired children has
been reported in a series of articles (Bess, 1982; Bess & Tharpe, 1984, 1986b). One
major finding from this study was that almost 50% of the children had either
repeated a grade or were receiving special services through the school district.
Further comparisons were made between a smaller sample (n = 25) of these
unilaterally hearing-impaired children and a matched group of normal-hearing
children. Klee & Davis-Dansky (1986) found that the scores for the two groups were
not significantly different on a battery of standardized language tests. The two
Robert F. Oyler is currently a doctoral candidate in the Child Language Laboratory, at the
University of Arizona, Tucson, AZ 85721. Requests for reprints may be sent to him at this
address. Anne L. Oyler is a clinical instructor of audiology in the Department of Speech and
Hearing Sciences, University of Arizona, Tucson, AZ 85721. Noel D. Matkin is a professor of
audiology in the Department of Speech and Hearing Sciences, University of Arizona, Tucson,
AZ 85721.
201
© 1988, American Speech-Language-Hearing Association
Language, Speech, and Hearing Services in S c h o o l s
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groups also performed similarly on the Wechsler Intelligence Scale for Children-Revised (WlSC-R) (Wechsler, 1974) and on the Hiskey-Nebraska Test of Learning
Aptitude (Hiskey, 1955) (Culbertson & Gilbert, 1986; Klee & Davis-Dansky, 1986).
However, it should be noted that significant differences on the WISC-R were found
within the unilaterally hearing-impaired group based upon whether a grade had
been repeated (Kiee & Davis-Dansky, 1986) and upon degree of hearing loss
(Culbertson & Gilbert, 1986). (For a complete review of the literature regarding
unilateral hearing loss in children, see Bess & Tharpe, 1986a.)
Thus, in the first widely published report of a study involving school-aged
children with unilateral hearing losses, the conventional attitude that such impairments have minimal impact upon performance was strongly challenged. If indeed
such children are having difficulty in the academic setting, this finding has
far-reaching implications. Being unaware of the effects (direct or indirect) that a
unilateral hearing loss might have upon a child's academic performance leads to a
reactive or "failure-based" approach toward intervention. Conversely, being aware
of the potential adverse effects allows clinicians to adopt a proactive approach. That
is, through careful monitoring of the child's academic progress, intervention can be
implemented before the child fails. In this way, intervention efforts might be more
successful and the child might avoid the psychological effects associated with
failure (e.g., frustration, lower self-esteem, etc.).
Another reason awareness of the potential adverse effects of a unilateral hearing
loss is important is purely fiscal. It costs a considerable amount of money to educate
each child each year in a regular classroom. Avoiding grade repetition can save a
school district substantial amounts of money.
The purpose of this study was two-fold. First, we wanted to determine the
demographic distribution of unilateral hearing loss in a large metropolitan school
district. Second, we wanted to further investigate the academic performance of
school-aged children with unilateral hearing losses to determine whether the
findings reported by Bess and his colleagues accurately represented how these
children were doing in school.
Method
Through a comprehensive hearing conservation contract with a large local school
district (student population = -54,000), detailed audiologic records covering the
past 7 years were available for our review. These records included all comprehensive audiologic evaluations for students, grades K through 12, enrolled in the
district. The first step in this study was to retrieve the charts for all children with
unilateral hearing losses which had been documented by a certified audiologist.
This was accomplished by one of the authors (ALO), who reviewed the most current
audiogram for each child in the district who had been previously evaluated in our
clinic. During this review, any child with a unilateral hearing loss which migh t be
due to otitis media was eliminated from the sample. Information regarding subject
description (e.g., age, sex) and hearing loss (e.g., type, configuration, degree, ear
impaired) was also obtained from the charts.
With the cooperation of the director of special education, a detailed questionnaire
(see Appendix A) and a copy of the Pupil Rating Scale Revised (Myklebust, 1981)
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19 201-210 April 1988
was distributed to the teacher of each child identified. These materials were
distributed at the beginning of April to insure that the teacher would have had
ample opportunity during the school year to become familiar with the child who
was being rated.
Results
Demographics
Of the 54,090 children enrolled in the school district, 106 students with unilateral
hearing losses were identified (42 elementary, 19 junior high, and 45 high school).
This yields a prevalence in this population of approximately 2/1000. If there is any
error in this count, it would be an error of omission. This could occur if a child with
a unilateral hearing loss had been taken for an audiologic evaluation to an
audiologist other than those with whom the school district has a contractural
agreement and a copy of the results was not forwarded to the child's file; or, if a
child with a unilateral hearing loss had moved into the district and had not yet been
tested at the clinic. Because the audiologic services are provided free-of-charge to
the parents, it is not likely that many children fit in to the first category. Because the
rate of ingress is greater than the rate of egress in this region, it is likely the effect
of the second factor would be an inflation of our count rather than a reduction. Thus,
this estimate of the prevalence of unilateral hearing loss is felt to be accurate; and,
if anything, is on the conservative side.
Regarding the distribution of unilateral hearing loss in this sample, there were
slightly more males than females (58 vs 48) and almost twice as many children with
hearing loss in the right ear as in the left ear (68 vs 38). Almost three-fourths of the
losses [n = 78] were sensorineural in type. It should be noted that the conductive
losses In = 23] and the conductive component of the mixed losses [n = 5] in the
remainder of this population were long-standing and did not include active or
transient cases of otitis media. Among those with conductive losses, there were 9
children (almost half of this group) with atresia: four males and five females.
Interestingly, all had right ear anomolies. Other causes of conductive loss included
ossicular malformations and mastoidectomies.
Approximately two-thirds of the children [n = 63] had a hearing loss with a
relatively fiat configuration which could easily be placed into one of the four
traditional categories (i.e., mild/moderate/severe/profound). The distribution of the
degree of hearing loss for these children is presented in Table 1. Note that the
majority fall into the profound range.
For the other 43 children, a variety of audiometric configurations was seen. This
information is presented in Table 2. While the majority had a failing configuration,
rising, trough-shaped, and inverted trough-shaped configurations were also seen.
For all subsequent analyses, these children were included in the most appropriate
category.
Teachers' Responses
At the time the questionnaires were distributed (the end of April), 12 children
with unilateral hearing loss were no longer in the school district--7 had moved
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203
TABLE 1. Distribution of unilateral hearing loss by degree for
those children with relatively fiat configurations. (n = 63).
mild (26-45 dB)
n = 8
(12.7%)
moderate (46-65 dB)
n = 14
(22.2%)
n = 3
(4.8%)
n = 38
(60.3%)
severe (66-85 dB)
profound (->85 dB)
d u r i n g that school y e a r (i.e., 1985-1986) and 5 h a d d r o p p e d out o f school. This left
a p o t e n t i a l p o p u l a t i o n of 94 children. It should b e n o t e d that the t e a c h e r s '
p a r t i c i p a t i o n in this project was c o m p l e t e l y voluntary.
In r e s p o n s e to t h e initial mailing, 50 questionnaires (18 e l e m e n t a r y , 10 j u n i o r
high, a n d 22 high school) and 36 P u p i l Rating Scales-Revised (PRSR) (15 e l e m e n tary, 9 j u n i o r high, a n d 12 high school) w e r e returned. Because the q u e s t i o n n a i r e
c o n t a i n e d more useful information r e g a r d i n g the two o l d e r groups of students than
the PRSR a n d the initial r e s p o n s e r e p r e s e n t e d a p p r o x i m a t e l y 50% of each of those
groups, it was d e c i d e d that a s e c o n d m a i l i n g w o u l d be sent only to the e l e m e n t a r y
teachers. In addition: (a) T h e e n d of the school y e a r was r a p i d l y a p p r o a c h i n g a n d it
was s u g g e s t e d that the j u n i o r high and high school teachers w o u l d have less t i m e
available to t h e m to c o m p l e t e the materials; a n d (b) Bess a n d his colleagues, with
w h o m w e w a n t e d to c o m p a r e our results, had w o r k e d with e l e m e n t a r y children. I n
TABLE 2. Distribution of unilateral hearing loss by degree for those children without
relatively fiat configurations. (n = 43).
Configuration
Total
Degree
Falling
n = 23 (53.5%)
Rising
n = 13 (30.2%)
Trough-shaped
n = 5 (11.6%)
Inverted Trough-shaped
n = 2 (4.7%)
mild (n = 2)
mild-to-moderate (n = 1)
mild-to-severe (n = 4)
mild-to-profound (n = 5)
moderate (n = 2)
moderate-to-profound (n = 6)
severe (n = 2)
profound (n = 1)
mild (n = 2)
moderate-to-mild (n = 3)
severe-to-mild (n = 1)
moderate (n = 4)
severe-to-moderate (n = 1)
severe (n = 2)
mild/moderate (n = 4)
mild/severe (n = 1)
moderate/mild (n = 1)
severe/mild (n = 1)
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19 201-210
April 1988
response to the second mailing, 11 additional questionnaires and PRSRs were
returned.
Questionnaire. Four of the 61 questionnaires were unusable; thus the return rate
was 60.6% [n = 57]. From these, information relative to the following questions was
obtained:
1. How many of the children with unilateral hearing losses had repeated a grade?
Of the 38 responses to this question, it was indicated that 9 children (23.7%) had
repeated at least one grade, compared with a district-wide repeat rate of 2% for
grades K--8. Two of these nine children had repeated two grades each. Among
those failing at least one grade, the percentage of children with right ear
involvement who had repeated a grade was approximately five times as high as
the percentage of children with left ear involvement (34.8% v. 6.7%). The
percentage of children with a severe-to-profound loss who had repeated a grade
was about twice as high as the percentage of those with a mild-to-moderate loss
(36.7% v. 18.7%). Cell sizes would not allow further analyses. We were not able
to gather sufficient data in this study regarding etiology of the hearing loss or age
at onset to make comparisons along these dimensions.
2. What percentage of children with a unilateral hearing loss receive special
services in the school district? Of the 54 responses to this question, it was
indicated that 22 of these children (40.7%) were receiving some sort of special
services, compared with a district-wide rate of 8.6%. These services varied from
speech/language therapy two times per week to self-contained classroom placement. When the distribution of those receiving special services was evaluated
with a chi-square analysis (a) by ear and (b) by degree of loss, no statistically
significant differences were found. In other words, neither the ear involved nor
the degree of loss appeared to be a determining factor in the decision to provide
special services to these children. A slight trend was noted which suggested that
the more severe the hearing impairment, the more likely it was that special
services would be provided.
3. How do the teachers rate the "overall performance" of their students with
unilateral hearing impairment as compared to their classmates? The teachers
were asked to rate overall performance as: below average--defined as the bottom
25% of the class; average--defined as the middle 50%; or above average-defined as the top 25%. The entire sample In = 57] was rated on this question:
22.8% were rated as below average; 50.9% were rated as average; and 26.3%
were rated as above average. This is strikingly similar to the distribution one
would expect from any randomly-drawn sample. Further chi-square analyses
revealed no significant association between either ear or degree of loss and the
teachers' rating of the child's overall performance.
4. Are the unilaterally hearing-impaired children perceived by their teachers as
being underachievers or overachievers as compared to their classmates? The
teachers were asked to indicate their impression of the child's "intellectual
ability" along the same dimensions as they rated overall performance (i.e., below
average~average~above average). We reasoned that agreement between these
two ratings would suggest that the teacher felt the child was working at his/her
potential while disagreement would suggest that the teacher perceived the child
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205
either as an underachiever or an overachiever. Of the 43 responses to both
questions, 33 of the unilaterally hearing-impaired children (76.7%) were viewed
by their teachers as working at their potential. Of the 10 children (23.3%) who
were not rated the same on both measures, three were rated higher on overall
performance than on intellectual ability (i.e., overachievers) and seven were
rated higher on intellectual ability than on overall performance (i.e., underachievers). In other words, it appears that the majority of these children who are
not working at their potential are viewed by their teachers as underachievers.
Pupil Rating Scale R e v i s e d (PRSR). The PRSR is a screening tool for learning
disabilities. It consists of a questionnaire which is completed by the teacher, has
been normed for children from 5 to 14 years of age, and has been shown to be
sensitive for different types of disabilities. For example, a recent study by Obringer
& Matkin (1986) found it was sensitive to differences in the performance of children
with central auditory disorders as compared to the normative sample.
All 47 of the PSRSs were usable; thus, the return rate was 50%. The norms for the
PRSR and the mean scores from the unilaterally hearing-impaired children are
compared in Table 3. There were no significant differences on the Orientation and
the Motor Scales. The unilateral group did score lower than the norm on the
Auditory Comprehension, Spoken Language, and Personal-Social Behavior scales.
The most notable difference was on the Personal-Social Behavior scale, where
approximately 33% of the unilateral group scored lower than the first standard
deviation below the mean. Recall that in a normal distribution, only 16% of the
scores are expected to fall in this range.
An item analysis was performed to identify which specific items were contributing to the differences. Those items significant beyond the .01 level were: comprehending word meanings and attention (p < .01); story telling and responsibility (p
< .005); completion of assignments (p < .001); and, adapting to new situations (p <
.0005). It is of interest that most of these items, while not considered auditory
learning problems per se, are factors which may well influence academic success.
Discussion
Demographics
The prevalence of unilateral hearing loss has been estimated at rates ranging from
1:1000 (Everberg, 1960a) to 13:1000 (Berg, 1972). The prevalence found in this
TABLE3. Comparison of the mean scores for the unilaterally hearing-impaired children with
the norms on the PRSR.
Scale
Norm
Group mean
t
p
Auditory comprehension (n = 45)
Spoken language (n = 45)
Orientation (n = 45)
Motor coordination (n = 47)
Personal-social behavior (n = 43)
13.24
16.35
13.68
9.68
26.98
12.31
15.13
13.53
9.36
24.47
1.86
2.24
0.34
1.28
2.99
<.05
<.025
NS
NS
<.005
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19 201-210 April 1988
study (-2:1000) is closer to the lower end of this range. Perhaps Berg's estimate
included children with any type of hearing impairment (i.e., sensorineural or
conductive, including transient otitis media) and is therefore more inflated than
either Everberg's estimate of"unilateral deafness" or the findings from the current
study.
Everberg (1960b) reported a greater prevalence of unilateral hearing loss among
males than females (62.3% v s 37.7%). Bess and Tharpe (1984, 1986b) reported a
slightly greater prevalence among females than males (55.0% v s 45.0%). Of the 106
children originally identified in this study, 58 were boys (54.7%) and 48 were girls
(45.3%). Thus, the findings of this study support the greater prevalence of unilateral
hearing loss among males, although not to the extent reported by Everberg. This sex
difference might have been expected, since the prevalence of bilateral hearing
losses is also higher among males than among females--53.7% v s 46.3%---according
to national statistics (Karchmer, 1985).
Everberg (1960b) also reported a slightly greater percentage of left ear impairment than right ear impairment (52.5% v s 47.5%). In contrast, Bess and Tharpe
(1984, 1986b) reported a greater percentage of right ear impairments among their
smaller, more extensively studied sample (62.5% v s 37.5%). Of the 106 children
originally identified in this study, 68 had a right ear impairment (64.2%) and 38 had
a left ear impairment (35.8%). Thus, the findings of this study support those
reported by Bess and Tharpe.
In summary, unilateral hearing loss is a disorder with fairly low prevalence. Our
study suggests: (a) that boys and girls are affected at roughly equivalent rates; (b)
that the right ear is approximately twice as likely to be involved as the left; and, (c)
that the degree of loss will most often be severe-to-profound.
Academics
Bess and Tharpe (1984, 1986b) reported a failure rate of 35% among their subjects
with a unilateral hearing impairment. While their figure is higher than that found in
the current study (i.e., 23.7%), both rates are remarkably similar when compared
with the general failure rate for the corresponding school district. In the Metro
Nashville district, the general failure rate was 3.5% for K-6 (Bess & Tharpe, 1986b).
In the district we studied, the general failure rate was 2% for K-8. Thus, in both
studies, children with unilateral hearing losses were at much higher risk for
academic failure than the general population. That risk is approximately 10 times
higher than for the population as a whole.
In addition to those children who were reported to have repeated one or more
grades, there were the additional 5 children with unilateral hearing losses who
dropped out of school. This represents approximately 5% of the original population.
While we cannot attribute dropping out of school to their hearing loss, these
children must also be considered academic failures.
Bess, Klee, and Culbertson (1986) reported that a recurring profile among the
unilaterally hearing-impaired children who experienced academic difficulty included: (a) early age of onset; (b) severe-to-profound hearing loss; and (c) right ear
impairment. Sufficient data regarding age at onset were not gathered in this study
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Hearing Loss
207
to allow comment; however, the importance of degree of loss and ear impaired were
supported by our findings. The percentage of children repeating a grade was
approximately two times higher for those with a severe-to-profound loss than for
those with a mild-to-moderate loss and was approximately five times higher for
those with right ear involvement than for those with left ear involvement. In other
wi3rds, children with a severe-to-profound unilateral hearing loss involving the
right ear have the highest risk for academic failure.
In the current study, the percentage of children receiving special services was
approximately five times the district average (40.7% vs 8,6%). This percentage is
considerably larger than that reported by Bess and Tharpe (1986b); only 13.3% of
their sample needed resource help. They reported neither the average for their
district nor the range of services, so further comparisons are not possible. There is
no ready explanation for this difference. Perhaps the Tucson district fails fewer
children but places more in special programs than does the Nashville district.
The most puzzling result of the current study was that teachers did not differentiate unilaterally hearing-impaired children from their classmates. For example,
teachers rated the overall performance of most of these children as adequate. Yet, 5
times as many children were receiving special services and 10 times as many had
repeated one or more grades. Perhaps repeating a grade and/or receiving special
services allows them to compete successfully in the classroom. Another possibility
is that our questionnaire was not sensitive to the specific problems experienced by
the unilaterally hearing-impaired children. Or, as suggested by the findings from
the Pupil Rating Scale Revised, perhaps the difficulties these children have in the
academic setting may not stem from their unilateral hearing loss but may result
instead from a more generalized language and learning disorder.
Conclusions
In summary, we have provided evidence that a unilateral hearing loss can place
a child at risk for academic failure, especially if the loss is in the severe-to-profound
range and/or the right ear is involved. Children with unilateral hearing loss thus do
not represent a homogeneous population. We by no means intend to imply that a
unilateral hearing loss is either the direct or the only cause of these children's
academic difficulties. However, it is possible that more aggressive intervention is
required for this population to perform well in school. Clinicians should, therefore,
carefully monitor the academic progress of unilaterally hearing-impaired students.
Future research in this area should attempt to: (a) determine the types of special
educational services the unilaterally hearing-impaired students are receiving and
the effectiveness of such intervention; (b) determine what psychoeducational and
psychosocial measures most effectively identify those students who are at risk for
failure; (c) explain the poorer academic performance of this population; and, (d)
explain why children with right ear unilateral hearing losses have the higher risk for
academic failure.
ACKNOWLEDGMENTS
We would like to acknowledge the contribution of Colleen Wilcox, Ph.D., Director of
Special Education for the Tucson Unified School District in Tucson, Arizona. Without her
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19 201-210
April 1988
support and assistance, this study could not have been completed. Preparation of this article
was supported in part (RFO) by the U.S. Department of Education Grant No. G008301459.
REFERENCES
BERG, F. S. (1972). Educational audiology: Hearing and speech management. New York:
Grune & Stratton
BESS, F.H. (1982). Children with unilateral hearin~ loss. Journal of the Academy of
Rehabilitative Audiology, 15, 131-144.
BESS, F. H., KLEE, T., & CULBERTSON,J. L. 11986). Identification, assessment, and management of children with unilateral sensorineural hearing loss. Ear and Hearing, 7, 43--51.
BESS, F. H., & THARPE, A. M. (1986a). An introduction to unilateral sensorineural hearing loss
in children. Ear and Hearing, 7, 3-13.
BESS, F. H., & THARPE, A. M. (1986b). Case history data on unilaterally hearing-impaired
children. Ear and Hearing, 7, 14-19.
BESS, F. H., & THARPE, A. M. (1984). Unilateral hearing impairment in children. Pediatrics,
74, 206--216.
CULBERTSON, J. L., • GILBERT, L. E. (1986). Children with unilateral sensorineural hearing
loss: Cognitive, academic, and social development. Ear and Hearing, 7, 38--42.
EVERBERG, G. (1960a). Etiology of unilateral deafness studied in a series of children and
young adults. Annals of Otology, Rhinology & Laryngology, 69, 711-730.
EVERBERG, G. (1960b). Unilateral total deafness in children. Clinical problems with a special
view to vestibular function. Acta Otolaryngologiea, 52, 253-269.
HISKEY, M. S. 11955). Hiskey-Nebraska Test of Learning Aptitude. Lincoln, NE: Union
College Press.
KARCrlMER, M. A. (1985). A demographic perspective. In E. Cherow, N. D. Matkin, & R. J.
Trybus (Eds.), Hearing-impaired children and youth with developmental disabilities: An
interdisciplinary foundation for serl~ice. Washington, DC: Gallaudet College Press.
KLEE, T. M., & DAVlS-DANSKY,E. (1986). A comparison of unilaterally hearing-impaired
children and normal-hearing children on a battery of standardized language tests. Ear and
Hearing, 7, 27~37.
MYKLEBUST, H. R. 11981). The Pupil Rating Scale Revised. New York: Grune & Stratton.
NORTHERN, J. L., & DOWNS, M. P. 11978). Hearing in children (2nd ed.). Baltimore: Williams
& Wilkins.
OBRINGER, S. J, & MATKIN,N. D. 11986). Use of The Pupil Rating Scale (Revised) to initiate
referral for central auditory testing. Manuscript submitted for publication.
WECHSLER, D. (1974). Wechsler Intelligence Scale for Children--Revised. New York: The
Psychological Corporation.
Received March 3, 1987
Accepted August 24, 1987
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209
Appendix A
TUCSON UNIFIED SCHOOL DISTRICT
P.O. Box 40400
1010 East Tenth Street
Tucson, Arizona 85717
April 30, 1986
TO: Teachers of Students With Unilateral Hearing Losses
FROM: Dr. Colleen B. Wilcox, Director, Special Education
Recent research reports have indicated that children with a unilateral hearing loss may have
difficulty in educational settings. This is contrary to the long-held belief that "one good ear
was enough to function adequately in the classroom." In response to these findings, we are
seeking information on the children in TUSD with known unilateral hearing losses. Please
complete the enclosed form on the student indicated below (the Myklebust Pupil Rating Scale
and the questionnaire below). This should take about 15-20 minutes. The results will allow
us to determine if the unilaterally hearing-impaired students in TUSD are experiencing any
academic difficulties and if follow-up study is necessary.
Please return the completed forms through district mail by May 16, 1986, to my office.
Thank you for your time.
Student's Name
DOB
Age__
Sex
School
Grade
Where does this student typically sit?
Has this student ever been held back in school?
What grade?
Special services currently received by this student (type and frequency)
Student's progress in special programs
Please indicate your impression of this student's intellectual ability regardless of formal I.Q.
scores.
Above Average _ _
Average _ _
Below Average
If formal I.Q. given, what test
Overall S c o r e _ _
Verbal__
Performance_
Top 25% of class
Average
Lower 25% of class
Attention & concentration
Ability to follow directions
Reading skills
Written language skills
Spelling ability
Arithmetic skills
Ability to express self
Attitude toward studies
Group participation
Peer relationship
Emotional stability
Overall progress
Name of person completing this form
AN EQUAL OPPORTUNITY EMPLOYER
210
Language, Speech, and Hearing Services in Schools
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Date
19 201-210
April 1988