Abstract
Integration and full inclusion of children with special needs into regular settings is a topic that has drawn considerable attention in the special education and early intervention literature. The purpose of this paper is to search for an answer to the question of "how to work towards effective integration and as an ultimate goal, to effective inclusion of hearing impaired children in developing countries." In an attempt to answer this question, firstly very briefly a review of current perspectives on integration and inclusion will be given. Secondly, the findings of an investigation into integration of hearing impaired children in a developing country will be reported. Following that, place will be given to a proposal of a model for the education of hearing impaired children in developing countries where some of the services are not yet available or yet developing.
Key words: Hearing impaired, education of hearing impaired children, integration, mainstreaming, inclusion, special needs, handicapped children, special education.
Introduction
Integration of hearing impaired children into the mainstream schools of their hearing peers has already been well established in the Western part of the world. Education Acts implemented in U.S.A., Britain and Canada, as well as in other countries established the principle of integration in these countries and opened the way for other countries to follow.
There is now a growing trend in education of handicapped children in general towards integrating them into the society and into the educational system fully, and this new concept is called 'inclusion'. Full inclusion of children with special needs into regular settings is a topic that has drawn considerable attention in the early intervention literature" (Pohlman and McWilliam, 1999). Mittler (2000), explains that "inclusion is not about placing children in mainstream schools. It is about changing schools to make them more responsive to the needs of all children."
There are several benefits expected of mainstream education for hearing impaired children whether it is possible by placements in integration classes or whether it is possible through inclusion. One benefit is to have a constant input of a naturally spoken language when the aim is to acquire the spoken language of the society. Harrison states that integration is "an integral part of a natural auditory approach to the development of spoken language in hearing impaired children." One of the principles of the auditory-verbal therapy is, "Supporting the concepts of mainstreaming and integration of children with hearing impairments into 'regular' education classes with appropriate support services to the fullest extent possible." Auditory-verbal therapists advocate integration as part of the auditory-verbal philosophy. Nolan and Tucker pointed out to the need of ''a naturally oral environment" and to the importance of motivation and also to good standards back in 1981, "where ... the motivation to achieve good oral standards is high" in integration.
Gregory and Bishop point out to another benefit of mainstream placements, which is having access to 'a richer and wider curriculum' than that available in a special school. Yet another benefit of mainstream placement is the social benefits of educating the child near his/her neighborhood, thus providing a social circle of home and a local school with hearing friends from the same community, preventing isolation from 'the hearing peers' and society in general. This would facilitate the child's integration into the hearing society as this is the ultimate aim.
Purpose of this Paper
The purpose of this paper is to offer a transitional model towards inclusion of hearing impaired children in developing countries where services for the hearing impaired are not providing even the basics, and the educational system in general is yet developing. To meet this purpose, answers to the following question will be offered in this paper:
How can we work towards effective integration and as an ultimate goal, to effective inclusion of hearing impaired children in developing countries?
In an attempt to answer this question, firstly very briefly a review of current perspectives on integration and inclusion will be given. Secondly, some of the findings of an investigation into integration of hearing impaired children in a developing country will be reported. Following that, place will be given to a proposal of a 'workable' model for the education of hearing impaired children in developing countries where some of the services are not available or yet developing.
CURRENT PERSPECTIVES
The passage of laws has compelled educational systems to make available for handicapped students a public education that approximates as closely as possible the one that is available to non-handicapped students. This brought forward a very progressive concept, when till then education of hearing impaired children was mainly segregated and took place in boarding schools. In Britain, Gregory and Bishop report that the 1981 Education Act implemented in 1983, asks that "all children for whom the L.E.A. decide to determine special educational provision be made ... are to be educated in ordinary schools, in so far as practicable," (D.E.S. Circular 8/81). The authors point out to the fact that in U.K., "even prior to the 1981 Education Act, most children with a hearing loss were educated in ordinary schools." The passage of such laws as well as a growing sensitivity towards children's rights and equality in every aspect of life resulted in trends mainly in the direction of placements increasingly in favor of mainstream classes.
A very progressive step in special education has been the acceptance of the concept, "the least restrictive environment". With the statement of Public Law 94-142, implemented in 1977; "Each hearing impaired child is to be educated in the least restrictive environment that is appropriate to his or her educational needs," the road to integration and inclusion was made open. As Geers (1990) has pointed out, certain legislations require that "handicapped children receive a free and appropriate education in the least restrictive environment, which often is interpreted to mean mainsteaming as early as possible."
A Big Challenge
As well as opening many closed doors, on the other hand, this statement brought about a big challenge to the educators when the topic is education of the hearing impaired child. This is because as Francis et al. (1999) states very rightly: "Challenges in overcoming the language delays associated with deafness, however, represent an impediment to the objective of equal educational opportunities for children with significant hearing disability."
In relation to developing countries, Lowe points out to the needs of hearing impaired children, "The fact that general standards of education in developing countries are rarely meeting the needs of non-handicapped children should not deter professional people from doing everything they can to provide an appropriate early intervention program for hearing impaired children," (Lowe, 1993). The needs of hearing impaired children require other conditions as well as early intervention programs all of which, in the course of this paper will be referred to as 'prerequisites'.
The objectives of equal educational opportunities for children with significant hearing disabilities can only be reached if certain prerequisites are met. The prerequisites to successful inclusion, integration or successful education of hearing impaired children, whereever the child is, whether inclusive or not, can be briefly grouped under two main categories: Conditions that meet the needs of children in general, maximizing growth and development in all areas of learning; and those facilities and services meeting the specific needs of children with hearing impairements, again maximizing growth and development in all areas of learning.
Prerequisites to Successful Education, Integration and Inclusion of Children with Hearing Impairements:
A brief discussion of the five prerequisites to successful education, integration and inclusion of children with hearing impairements follows.
Needs of Children within General Educational System are:
There are some very specific needs of hearing impaired children that should be addressed to in addition to above, if it is the desire of educators to provide for maximum development and educational attainment. These needs may be grouped briefly under the headings of Audiological Needs and Communication Needs.
Audiological Needs Specific to Hearing Impaired Children are:
"A good acoustic environment" may be defined as that situation in which the noise that is irrelevant to us is suppressed as far as possible, while the useful sounds, those that interest us, stand out clearly and truly and easily distinguishable (Borrild, 1980). One of the main factors competing against reception of clear speech signals is unfavorable acoustic environment present in mainstream classrooms in the form of noise and reverberation.
Communication Needs Specific to Hearing Impaired Children are:
If the aim is functional and curricular inclusion, learning and developing at his/her own pace, the hearing impaired child needs some form of support to keep up with the rather different pace of the lesson taking place in mainsteam classes. The supportive services may be delivered in various forms.
Supportive Services Provided Meeting Educational Needs of Hearing
Impaired Children in Mainstream Classes:
In classroom may be delivered
by:
Acknowledgement of Needs:
Types of Integration
A literature review on types of integration that takes place in mainsteam settings defines several types. Although authors claim that 'inclusion is a different philosopy from integration', what is going to happen to the hearing impaired child will very much be dependant on the transformation of the 'normal' educational system and until this is fully realized, the child will be in the position of experiencing one of the following types:
Discussion in the literature is abundant as to the advantages and disadvantages of these types. Moss (1987) is in agreement with those writers that "mere contact between handicapped and non-handicapped pupils does not indicate integration." However, Moss evaluated in her study "functional integration" from the point of attitudes towards acceptance and adaptation, and not taking into account curricular integration. Gregory and Bishop (1989) point out to the fact that locational integration does not neceessarily make functional or curricular integration happen: "The deaf child does not experience 'normal' education simply by taking his place in the mainstream class." Alderman (1988) too, feels the need for curricular integration to take place, "We should be aiming at functional and curricular integration. Because if effective learning does not take place during the school years, the child will be put at disadvantage and exclusion later in life, at a much greater degree.
Gregory and Bishop have demonstrated that "the deaf child does not experience 'normal' education simply by taking his or her place in the mainstream class". ". …as to the promise of a wider curriculum, it seems that often the deaf child has not the competence in spoken language to benefit from the orally presented wider curriculum of the mainstream schools" (Gregory and Bishop, 1989). It seems obvious that exposure to the normal curriculum does not necessarily give access to that curriculum. Yet, many hearing impaired children are placed in mainstream classes by parents and educators with the hope that this will happen.
Certain legislations are also passed in Turkey, encouraging the integration of hearing impaired children in mainstream classes in public schools. Consequently, more and more children are now enrolling in public schools, however without the provisions for the specific needs of this population.
Research Needed
Despite the rapid and significant changes in the education and health provision for hearing impaired children in many countries, and accompanying literature on diagnosis in infancy and early years, provision of hearing aids, better hearing aid technology, introduction of cochlear implants, also improvement of the acoustic environment and short microphone distance, provision of support services; the implementation of these facilities and services in developing countries has been a major problem. The lack of the prerequisite conditions create serious barriers for hearing impaired children to develop their mother tongue as well as keep learning in all areas. Because the literature of the Western world is abundant with the benefits of integration, and now also with inclusion, the parents and teachers think that it happens by placement.
There has been little or no research into effectiveness of integration of this kind in Turkey; into the educational attainments and language development of these students. How is each hearing impaired child doing in the way of developing language effectively, learning academic content? Is he/she motivated to go on learning, experiencing success? Is he/she developing self-esteem, establishing social relationships, developing into a happy and healthy individual as well? Many questions come up that need to be answered when the concern is children and their education. Therefore a research was designed to search some of those questions, and the findings will be given in summary below. In so doing, it is hoped that the reader may have a glimpse of the difficulties lived in the field of education of the deaf in some of the developing countries, and we perhaps be looking for different solutions for different situations around the world, although the ultimate goal is the same.
The results of an investigation into educational outcomes of primary and secondary school hearing impaired students in mainstream programs in a city in Turkey will be reported. It is hoped that the results may shed some light on to the potential barriers to quality of education wherever hearing impaired children are placed in developing countries.
The Aim
One objective of the study was to gather data on language, literacy and academic success of hearing impaired students as outcome measures for successful integration.
Another objective was to analyze this data against a number of significant factors, student and environment factors, previously identified in the literature, (Geers, 1990; Powers, 1999b).
The main fieldwork involved interviewing by use of a questionnaire, all the mainstream classroom teachers of the children studied, observation of their classroom and facilities, and the researcher assessing reading comprehension by individually working with the children. The resulting data consisted therefore mainly of reading assessment scores, ratings given by the mainstream classroom teachers, and analysis of the answers to the interview questionnaire. The present paper draws on a relatively small element of the interviews and data collected through the interview and questionnaires.
Outcome Measures
The outcome measures used in this study cover three areas that are important for a hearing impaired child's development and learning in the classroom: Performance in verbal communication, reading comprehension, and general academic performance.
The primary problem the hearing impaired child is faced with is communication and developing a native language. However, most hearing impaired children, either in special schools or as Powers states, in mainstream schools are able to "...communicate through spoken English, the use of residual hearing through hearing aids, and speech-reading," (Powers, 1999 a; Clark, 1989). Also authors agree that educational achievement is enhanced by the use of verbal communication, as Francis et al. reports from Trybus and Karchmer, (1977) and also from Holt, (1993). This is true simply because verbal communication is the medium of teaching in the classroom as well as the medium of reading and writing. In fact this is the mode the child will be faced with in the society and also it is the desire of the majority of parents in Turkey, that their child should be aquiring verbal communication. Moreover, mainsteam classes in Turkey employ standard verbal communication, "that forms the foundation for future academic development and vocation" (Francis et al., 1993). One way of assessing verbal communication would be assessing spoken language of the students and their reading comprehension.
Outcome measures used in this study are:
The Subjects
All the children included in the study were drawn from ordinary primary and secondary schools. All the hearing impaired children were taught in mainstream classes for 100% of their school time. The hearing impaired children, forty-six children in the mainstream formed two distinct groups. The groups differed in the facilities and types of support provided, type of education received, and also in the type of early intervention the children received prior to placement.
One of the groups contained all 'local' hearing impaired children in mainstream classes in primary and secondary public schools in town, who were under the responsibility of L. E. A. In this study, they will be refered to as 'local mainstream children' for abbreviation purposes.
The other group consisted of all hearing impaired children who were under the responsibility of IÇEM- Center for Hearing Impaired Children, but they were placed in mainstream classes in a neighbouring primary and secondary public school within the same campus of Anadolu University.
Inclusion criteria for the study
Student demographics
The Setting
The settings that hearing impaired children were placed could be grouped into two distinctly different educational settings where also provision of services and early intervention was also different.
> Local mainstream schools representative of the general educational system in Turkey.
> IÇEM is an education and research center of Anadolu University, located in its campus. It follows closely the auditory-oral philosophy and has developed into a progressive education center for hearing impaired children and families, with also teacher training degree programs. Detailed description about this project is available in the literature, (Clark and Tüfekçioglu, 1994; Büyükersen, 1996; Tüfekçioglu, 1996; Tüfekçioglu, 1988). In this setting, the audiological needs of children are addressed as shown below:
To meet the communication needs of their hearing impaired students, the teachers at IÇEM spend sustained efforts to provide the following:
The results of the investigation are given under three main topics: Performance in spoken language, reading comprehension, and general academic performance.
Performance in Spoken Language
The results for performance in spoken language are given under the headings of comprehension of spoken language, use of spoken language, and speech intelligibility in Tables 1-3. A five-point scale is used to give individual ratings to each child's comprehension of spoken language, use of spoken language and speech intelligibility. The number of children in each group of rating as a level of performance is then calculated in percentage for each typical educational setting and given under the headings of Local Mainstream children as well as IÇEM Mainstream children. In this format, it is possible to observe the differences displayed in performance as a function of their respective educational setting as well as the type of intervention received prior to school entrance.
· Comprehension of Spoken Language The results are given in Table 1, as a function of educational settings and type of intervention received.
| ICEM Mainstream | Local Mainstream | |
| Rating by Teacher | Percentage of students | Percentage of Students |
| Near normal | 50% | 5% |
| Fairly satisfactory | 33% | 5% |
| Some understanding | 16.5% | 17.5% |
| Limited understanding | 0% | 52.5% |
| Does not understand | 0% | 20% |
One example of a taxanomy of language form is "grouping or listing children's utterances according to the number of words as: single-word utterances, two-word utterances, three-word utterances, etc." (Bloom and Lahey, 1978). A five-point scale is used to give ratings to students' level of spoken language form. The results are given in Table 2, as a function of educational settings and type of intervention received.
Table 2: Use of Spoken Language IÇEM Mainstream and Local Mainstream Children's Performance
| ICEM Mainstream | Local Mainstream | |
| Rating by Teacher | Percentage of students | Percentage of Students |
| Sentances | 50% | 32.5% |
| Three or more words | 50% | 20% |
| Two words | 0% | 5% |
| Single words | 0% | 20% |
| Only vocalizations | 0% | 22.5% |
The speech intelligibility of each hearing impaired child in a mainstream class was rated by his or her mainstream teacher who was involved in the teaching of that child. A five-point scale was used to give ratings to hearing impaired children's level of intelligibility after Markides, (1989). The teacher was asked to consider carefully the speech of the child in her class and to rate it on the following 5-point scale:
The results are given in Table 3, as a function of educational settings and type of intervention received.
Table 3: Speech Intelligibility IÇEM Mainstream and Local Mainstream Children's Performance
| ICEM Mainstream | Local Mainstream | |
| Rating by Teacher | Percentage of students | Percentage of Students |
| Near normal | 66.7% | 7.5% |
| Very easy to follow | 16.6% | 7.5% |
| Fairly easy to follow | 16.6% | 10% |
| Rather difficult to follow | 0% | 20% |
| Very difficult to follow or unintelligible | 0% | 35% |
The reading performances were assessed individually by using a set of comprehension questions during an oral interview session. The child was asked to answer the questions after reading a simple text with a simple picture that his or her mainstream classroom teacher provided, which she had used with the child previous to the assessment. The results are given in Table 4, as a function of educational settings and type of intervention received.
Table 4: Reading Performance- Comprehension IÇEM Mainstream and Local Mainstream Children's Performance
| ICEM Mainstream | Local Mainstream | |
| Rating by Teacher | Percentage of students | Percentage of Students |
| Discuss main idea | 0% | 0% |
| Give good answers | 75% | 0% |
| Give short answers | 25% | 7% |
| Only decoding, no comprehension | 0% | 52% |
| Can not decode or read and answer | 0% | 41% |
Academic Performance
Academic performance is assessed by each student's mainstream class teacher in comparison with the group of hearing students the child was placed with. A four-point scale was used to give ratings to each hearing impaired student, judging by the relative amount of access the child had to curriculum presented to the class in general and was able to cope with. The results are given in Table 5, as a function of educational settings and type of intervention received.
Table 5: Academic Performance IÇEM Mainstream and Local Mainstream Children's Performance
| ICEM Mainstream | Local Mainstream | |
| Rating by Teacher | Percentage of students | Percentage of Students |
| Above class average | 16.7% | 0% |
| Same as class average | 66.7% | 7.5% |
| Below class average | 16.7% | 45% |
| Much below class average | 0% | 47.5% |
The subjects who were mainstreamed during elemantary grades with individualized regular support in language and reading, but who also received early intervention and attended an auditory-oral preschool and nursery program were achieving near or parallel to their hearing classmates. Individualized regular support in language and reading is very important for the hearing-impaired child for his/her speech and language learning. "As well as subject-based support teaching, opportunity has also to be found during the school day for specialist tuition in the development of speech and language skills," (Alderman, 1988). Ewing and Ewing clearly stated that only in this "... kind of rich verbal environment a child's vocabulary grows, and his ability to use sentences develops … if a very considerable amount of individual attention is given to every child. … Fully trained and qualified teachers of the deaf alone can fulfill their (severely and profoundly deaf children) complicated needs."
Later learning can only build on a strong foundations of receptive and spoken language. The findings of this research support this thesis, especially when it is only one class teacher expected to do all of the teaching and tutoring. Moreover, as Donnelly (1999) pointed out, if these teachers are working "in the circumstances imposed by the National Curriculum, ... hearing impaired children are caught in a vicious form" of unrealistic expectations.
The subjects who were enrolled straight into mainstream classes without any prior or earlier education or parent support, who missed out on hearing aids, individualised support, demonstrated very poor performance in comprehension of spoken language, use of spoken language, reading comprehension and academic learning. The results of another research into the reading comprehension of hearing impaired students in mainstream classes in the same city schools agree with these results, also showing very low levels of comprehension in the disadvantaged group when compared with hearing impaired students who benefited the 'prerequisite' conditions outlined earlier (Girgin, 2000).
At school or outside school, local mainstream children were not supported by qualified teachers of the deaf or by any other staff. Most of the teaching was directed toward the majority of children who were hearing children. The ratio of hearing impaired children to hearing children was on average one in 35. There was no provision of FM-radio hearing aids or group aids or speech trainers to improve the reception of speech signals in the presence of background noise and reverberation present in the ordinary classrooms. This resulted in a considerable disadvantage in receiving the speech delivered in the ordinary classroom, when this speech was to be the basis for understanding and learning spoken language.
The results of the present study have shown that the mainstreamed and orally educated, severely and profoundly hearing impaired children in this study, were able to develop speech and language only if they received an early and effective intervention program, followed by primary and secondary education that was tailored to meet their audiological and communication needs. Those children that succeeded had also attended a very strong auditory-oral preschool and nursery special education program with reverse integration facilities.
These results agree with the findings of Geers study showing that, "for orally educated, profoundly hearing impaired children, special education throughout elemantary school" or preschool may improve their success rate in the mainstream. What needs to be emphasized in this statement is: "For these children, successful integration into regular classrooms is the result, not the cause, of well-developed language and reading skills" (Geers, 1990), that they were able to acquire in the special or supportive settings meeting all of the prerequisite conditions. In this particular city of Turkey, hearing impaired children in mainstream classes that were attached to IÇEM received the degree of special help and services they needed, however those in local schools did not receive the services nor the special help they needed.
How Do We Justify Appropriate Placement with Hearing Impaired Children?
As Alderman points out (1988), continuous review and assessment of progress and placement is an integral part of education. "Students should be integrated for success, not failure. It is the student's ability (or readiness) to learn and progress in his current placement which determines if that placement is optimal" (Beswich and Owsley, 1988). It is all very well to work towards inclusion, but at the same time continuous review and assessment of progress and appropriate placement decisions need to be made alongwith the provision of the right kind of environment.
If placements are no longer made through automatic decisions but, discussions between professionals and parents focus "… on the needs of the children rather than on sweeping generalizations about the options themselves, if such discussions are handled correctly, the likelihood that the child will in fact be placed appropriately will be maximized" (Bernstein and Martin, 1992).
Safety Rules with Inclusion
The problem of education in a mainstream setting "is the dual dilemma of developing a mature linguistic system ... within each child and also providing access to the curriculum" (Hopwood and Gallaway, 1999).
We can not afford children to live in a dilemma or a 'survival' situation that Beswich and Owsley have pointed to:
"Dumping a handicapped child into a pool of normal children where he must sink or swim should not be permitted until all teachers have been trained to be lifesavers," (Beswich and Owsley, 1988).
Although we remain in IÇEM, just as Beswich and Owsley, strong advocates of integration for hearing impaired children, our experience in developing services in a developing country has taught us the same 'two things that they have pointed out:
The results of the research indicate that severely hearing impaired children also can acquire literacy and achieve normal or near to normal academic success in mainstream classes comparable to their hearing classmates, with the condition that they have received early diagnosis, early and appropriate hearing aids that have been monitored regularly, and have received early special education with parent guidance provided regularly to their parents. It should be said, however that these hearing impaired children who did display successful integration have also been subject to evaluation of their receptive and expressive language prior to placement decisions. Only those who were evaluated to be at a language level that would give access to the language of the ordinary classroom were included in the mainstream placement. Geers and Moog study also underlines this issue by reporting their research findings. The subjects in the Geers and Moog study, though they had profound hearing losses demonstrated "well-developed auditory speech perception skills." They also had well-developed spoken language skills with highly intelligible speech. The results of the present study also demonstrates, as in the Geers and Moog study, that the group who had good reading comprehension had good receptive and spoken language skills in contrast to non-comprehending group. The group who had good receptive and spoken language skills had "the benefit of" early and appropriate amplification, parent guidance and "special education" delivered at a model school- "IÇEM", again in paralel to Geers and Moog study group.
It is important to note that the hearing impaired children in the present study have also received support services where their language development and academic development was enhanced through daily individual tutoring. The main factor leading to success in this respect was the provision of all of the prerequisite conditions. In conclusion, the results could be summarized in the following statements:
From the perspective of a developing country, the author of this paper believes, just as Mittler has stated regarding inclusion, that a totally different philosophy is necessary at least for hearing impaired children in Turkey to succeed fully in the mainstream settings. This is felt necessary because the present conditions inherent to the general system of education must change radically, if any hearing impaired child is to be placed for learning or for positive social and personal development. Until this radical change is effective nationwide, a transitional model towards inclusion is suggested to maintain quality in education offered to the hearing impaired child.
A Transitional Model Towards Inclusion
Considering the limitations in developing countries, a model center such as a specialist center in each city to provide for all the special services that a hearing impaired child and his/her family needs for developing the child to his/her full potential, may be proposed. This 'center of excellence' would be responsible for the organisation and provision of inclusion and reverse integration to set an example where the ideal conditions a hearing impaired child needs in inclusive settings would be met. This would, as a working model, provide a practice where standards and expectations could be set to a high standard of education. It would also serve as a practicum school for teacher training programs, which are very much needed in developing countries. A major problem of teacher training especially specific to the developing countries is that there are no truly good quality educational settings for handicapped children where the students in teacher-training could be placed for their practical experience.
A Look Into Future
The successful practices at IÇEM have evolved in the light of experience. Our experiences with severely and profoundly hearing impaired children and in developing programs for them at IÇEM have also taught us that the local culture and the general system of education in a country dictate certain limitations on to a practice. However progressive a philosophy such as 'inclusion' is in essence, the limitations of the country make it necessary for educators to find transitional models that serve best to the specific needs of hearing-impaired children in a developing country. It is hoped that the transitional models keep evolving along with the general educational system and supportive services, allowing for inclusion with quality.
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