Autism and Autism and DeafnessDeafnessBest PracticesBest Practices

Katie NunnKatie Nunn

1 out of 150 will be 1 out of 150 will be diagnosed with diagnosed with Autism.Autism.

http://www.autism-society.org/site/PageServer?http://www.autism-society.org/site/PageServer?pagename=FactsStatspagename=FactsStats

Autism and DeafnessAutism and Deafness

Autism has no single cause and no Autism has no single cause and no known causeknown cause

There is no data about the number of There is no data about the number of children with autism and deafnesschildren with autism and deafness

Diagnosing Autism Diagnosing Autism

Evaluations and TestingEvaluations and Testing While there is no one behavioral or communication test While there is no one behavioral or communication test

that can detect autism, there are screening checklists that that can detect autism, there are screening checklists that are now used. are now used. Autism Treatment Evaluation Checklist (ATEC) Internet Scoring Autism Treatment Evaluation Checklist (ATEC) Internet Scoring

Program, Program, Childhood Autism Rating Scale (CARS), Childhood Autism Rating Scale (CARS), Childhood Autism Test (CHAT), Childhood Autism Test (CHAT),

Most of these test are done by a physician, psychologist, Most of these test are done by a physician, psychologist, psychiatrist and the parentspsychiatrist and the parents

http://www.autismeducation.net/diagnosing.htmhttp://www.autismeducation.net/diagnosing.htm

Autism Treatment Evaluation Autism Treatment Evaluation Checklist (ATEC) Internet Checklist (ATEC) Internet Scoring ProgramScoring Program

This checklist was designed to help parents, This checklist was designed to help parents, researchers, and physicians determine if a researchers, and physicians determine if a specific kind of treatment is being successful specific kind of treatment is being successful for the child.for the child.

1 page document, free, can download online, 1 page document, free, can download online, rating scale, can be scored on the internetrating scale, can be scored on the internet

http://www.autism.com/ari/atec/atec-online.htmhttp://www.autism.com/ari/atec/atec-online.htm

Child Autism Rating Scale Child Autism Rating Scale (CARS)(CARS)

This test was designed to help differentiate between autism and This test was designed to help differentiate between autism and other cognitive impairments. other cognitive impairments.

The test helps to identify and diagnose autism in individuals ages The test helps to identify and diagnose autism in individuals ages 3 through 22 years and to estimate the severity of the disorder 3 through 22 years and to estimate the severity of the disorder

Combines parent reports and direct observation by the Combines parent reports and direct observation by the professional professional

The child is rated, a final score can indicate, non autistic, mild to The child is rated, a final score can indicate, non autistic, mild to moderately autistic, or severely autistic. moderately autistic, or severely autistic.

The scale is used to observe 15 items, relationship to people, The scale is used to observe 15 items, relationship to people, imitation, emotional response, body use, object use, adaptation to imitation, emotional response, body use, object use, adaptation to change, visual response, listening response, taste-smell-touch change, visual response, listening response, taste-smell-touch response and use, fear and nervousness, verbal communication, response and use, fear and nervousness, verbal communication, non-verbal communication, activity level, level and consistency of non-verbal communication, activity level, level and consistency of intellectual response, and general impressions. intellectual response, and general impressions.

This scale can be completed by a clinician or teacher or parent, This scale can be completed by a clinician or teacher or parent, based on observations of the child's behavior. based on observations of the child's behavior.

http://www.autism-world.com/index.php/2007/03/27/childhood-autism-rating-scalecars/http://www.autism-world.com/index.php/2007/03/27/childhood-autism-rating-scalecars/

CHATCHAT

The CHAT is a screening tool developed for The CHAT is a screening tool developed for pediatricians to use at the 18-month checkup pediatricians to use at the 18-month checkup for children. for children.

Clinicians complete 5 items based on Clinicians complete 5 items based on observation and ask parents to answer yes/no observation and ask parents to answer yes/no to an additional 9 items. Each section takes an to an additional 9 items. Each section takes an average of 5 minutes to complete. average of 5 minutes to complete.

If a child fails, they should be given another If a child fails, they should be given another CHAT a month laterCHAT a month later

Intervention Intervention Strategies for Strategies for Behavior ModificationBehavior Modification

Applied Behavioral Applied Behavioral Analysis (ABA)Analysis (ABA)

What is it: a systematic approach to the assessment What is it: a systematic approach to the assessment and evaluation of behavior, and the application of and evaluation of behavior, and the application of interventions that alter behavior. interventions that alter behavior.

Goal: To evaluate and modify one’s behavior in ways Goal: To evaluate and modify one’s behavior in ways such as:such as: teach new skillsteach new skills generalize or to transfer behavior from one situation to another generalize or to transfer behavior from one situation to another

(e.g., from communicating with caregivers in the home, to (e.g., from communicating with caregivers in the home, to interacting with classmates at school); interacting with classmates at school);

modify conditions under which interfering behaviors occur modify conditions under which interfering behaviors occur (e.g., changing the learning environment so as to foster (e.g., changing the learning environment so as to foster attention to the instructor); attention to the instructor);

reduce inappropriate behaviors (e.g., self injury or stereotypy).reduce inappropriate behaviors (e.g., self injury or stereotypy). http://www.centerforautism.com/aba/whatisaba.asphttp://www.centerforautism.com/aba/whatisaba.asp

Example of ABA…Example of ABA… Andy, a mainstreamed 1Andy, a mainstreamed 1stst grader diagnosed with hearing loss and grader diagnosed with hearing loss and

PDD tendencies, would constantly raise his hands straight up into PDD tendencies, would constantly raise his hands straight up into the air. This caused negative attention towards him from his the air. This caused negative attention towards him from his peers. Andy raised his hands as a self- stimulating activity. The peers. Andy raised his hands as a self- stimulating activity. The teacher evaluated his behavior and then created an intervention teacher evaluated his behavior and then created an intervention where she would touch Andy’s arms and tell him to put his hands where she would touch Andy’s arms and tell him to put his hands down when he raised them inappropriately. Within 7 days Andy’s down when he raised them inappropriately. Within 7 days Andy’s targeted behavior began to decline. The teacher decided to targeted behavior began to decline. The teacher decided to change the intervention to make it semiprivate. She gave Andy a change the intervention to make it semiprivate. She gave Andy a meaningful look when she wanted the target behavior to stop. meaningful look when she wanted the target behavior to stop. Andy’s target behavior continued to decline. Within 13 days of the Andy’s target behavior continued to decline. Within 13 days of the intervention taking place Andy’s behavior had been modified. This intervention taking place Andy’s behavior had been modified. This target behavior was no longer a distraction for Andy and his target behavior was no longer a distraction for Andy and his classmates.classmates.

Easterbrooks, S, & Handley, C.M. (2005-06). Behavior Change in Easterbrooks, S, & Handley, C.M. (2005-06). Behavior Change in A Student with a Dual Diagnosis of Deafness and Pervasive A Student with a Dual Diagnosis of Deafness and Pervasive Developmental Disorder: A Case Study. Developmental Disorder: A Case Study. American Annuals of the American Annuals of the DeafDeaf. . 150150, 401-407. , 401-407.

Sensory Integration Sensory Integration TherapyTherapy

What is it: A type of therapy that focuses on What is it: A type of therapy that focuses on improving abilities to take in sensory improving abilities to take in sensory information and process the information information and process the information productively. productively.

Goal: Sensory integration therapy is designed Goal: Sensory integration therapy is designed to help the child develop more appropriate to help the child develop more appropriate sensory input processing and responses and sensory input processing and responses and lessen self- stimulating behaviors or other lessen self- stimulating behaviors or other sensory related awkward behaviors.sensory related awkward behaviors.

http://autism.healingthresholds.com/glossary#term1890http://autism.healingthresholds.com/glossary#term1890

Example of Sensory Example of Sensory Integration (SI) TherapyIntegration (SI) Therapy

During sensory integration therapy, the child interacts During sensory integration therapy, the child interacts one-on-one with the occupational therapist and one-on-one with the occupational therapist and performs an activity that combines sensory input with performs an activity that combines sensory input with motion. Examples of such activities include:motion. Examples of such activities include: swinging in a hammock (movement through space); swinging in a hammock (movement through space); dancing to music (sound); dancing to music (sound); playing in boxes filled with beans (touch); playing in boxes filled with beans (touch); crawling through tunnels (touch and movement through crawling through tunnels (touch and movement through

space); space); hitting swinging balls (eye-hand coordination); and hitting swinging balls (eye-hand coordination); and balancing on a beam (balance). balancing on a beam (balance). http://autism.healingthresholds.com/therapy/sensory-integrationhttp://autism.healingthresholds.com/therapy/sensory-integration

Intervention Intervention Strategies to Strategies to Promote LanguagePromote Language

PECSPECS What is it: PECS: Picture Exchange What is it: PECS: Picture Exchange

Communication SystemCommunication System Picture boards, cue cards, photos, drawingsPicture boards, cue cards, photos, drawings

All of this can be used to help a child communicate All of this can be used to help a child communicate effectively and easilyeffectively and easily

Inexpensive Inexpensive Appropriate for all agesAppropriate for all ages Easily used in many different locations (school, home)Easily used in many different locations (school, home) Can be taught with little training to family and other care Can be taught with little training to family and other care

giversgivers However, may be cumbersome to transport multiple pictures However, may be cumbersome to transport multiple pictures

to various locations (ex. Vacation, forgot to bring hamburger to various locations (ex. Vacation, forgot to bring hamburger picture! picture! ) )

http://www.pyramidproducts.com/PicsforPECS2008Sample.pdf

Goal: to help nonverbal children or children with Goal: to help nonverbal children or children with language difficulties to access communicationlanguage difficulties to access communication

PECS: Stepping StonesPECS: Stepping Stones

Start with wants and needsStart with wants and needs Cookie, bathroomCookie, bathroom

Build up to sentencesBuild up to sentences I want a hamburger.I want a hamburger.

Questions and answersQuestions and answers Do you like milk?Do you like milk? No, I do not like milk. No, I do not like milk.

Example of PECSExample of PECS Johnny wants the fish crackers. He is trying to pull them off Johnny wants the fish crackers. He is trying to pull them off

the counter. The teacher sees this and walks over. Johnny the counter. The teacher sees this and walks over. Johnny looks at the teacher. The teacher waits 30 sec. The child does looks at the teacher. The teacher waits 30 sec. The child does not respond. “Johnny, what do you want?” the teacher asks. not respond. “Johnny, what do you want?” the teacher asks. Johnny points to the crackers. “What is that?” The child still Johnny points to the crackers. “What is that?” The child still does not respond. “Johnny, you want the orange fish does not respond. “Johnny, you want the orange fish crackers? Go get your picture off your board.” If the child does crackers? Go get your picture off your board.” If the child does not do this, get the PECS picture of the fish crackers off the not do this, get the PECS picture of the fish crackers off the velcro board. Have the fish crackers in one hand and the velcro board. Have the fish crackers in one hand and the PECS picture in the other. Place the PECS picture in the PECS picture in the other. Place the PECS picture in the hands of the student. Tell the student to give the PECS hands of the student. Tell the student to give the PECS picture back and then they will get the crackers. If the student picture back and then they will get the crackers. If the student is unable to do this, model it with another adult. Once the is unable to do this, model it with another adult. Once the student has given you the PECS picture immediately reward student has given you the PECS picture immediately reward them with the crackers and praise the child. “Good job. You them with the crackers and praise the child. “Good job. You wanted the orange fish crackers and you gave me the card. wanted the orange fish crackers and you gave me the card. Now you have the crackers.”Now you have the crackers.”

Floor TimeFloor Time What is it: A technique designed to help a child address their What is it: A technique designed to help a child address their

developmental challenges in a child centered waydevelopmental challenges in a child centered way Goal: To strengthen a child’s cognitive, emotional, social, and Goal: To strengthen a child’s cognitive, emotional, social, and

physical development with an emphasis on two way physical development with an emphasis on two way communication, expression of feelings, and develop of logical communication, expression of feelings, and develop of logical thought.thought.

It comes from the It comes from the DIR Model: DIR Model: Developmental, Individual Developmental, Individual Difference, Relationship-based approach. There are six Difference, Relationship-based approach. There are six developmental levels. These stages are:developmental levels. These stages are:

1. Self-regulation and interest in the world (3+ months)1. Self-regulation and interest in the world (3+ months)2. Forming relationships, attachment and engagement (intimacy) 2. Forming relationships, attachment and engagement (intimacy) (5+ months)(5+ months)3. Two-Way Communication (9+ months)3. Two-Way Communication (9+ months)4. Complex Communication (12-18+ months)4. Complex Communication (12-18+ months)5. Emotional Ideas (24-30+ months)5. Emotional Ideas (24-30+ months)6. Emotional Thinking (34+ months)6. Emotional Thinking (34+ months)

What it looks like…What it looks like… 2-3 objectives can be worked on at a time2-3 objectives can be worked on at a time Caregiver uses a calm voice or signer uses Caregiver uses a calm voice or signer uses

exaggerated signs in a slow, flow like way with exaggerated signs in a slow, flow like way with gentle looksgentle looks

Follow the child’s leadFollow the child’s lead No direct instructionNo direct instruction Use Floor Time as a daily activityUse Floor Time as a daily activity Toys and other activities can be used to Toys and other activities can be used to

encourage interactionencourage interaction Length of play will increase as appropriateLength of play will increase as appropriate

Example of Floor TimeExample of Floor Time A caregiver and a 9 month old are sitting on a blanket on the floor. A caregiver and a 9 month old are sitting on a blanket on the floor.

The baby reaches for a toy. The child can not get the toy. The The baby reaches for a toy. The child can not get the toy. The caregiver says, “Do you want the toy? Can you reach the toy?” caregiver says, “Do you want the toy? Can you reach the toy?” The child slaps his hands on his legs and begins to babble, but The child slaps his hands on his legs and begins to babble, but does not reach for the toy. The caregiver moves the toy closer to does not reach for the toy. The caregiver moves the toy closer to the child. “Do you want the toy still? Are you going to reach for the the child. “Do you want the toy still? Are you going to reach for the toy?” The child touches the toy but does not pick it up. The toy?” The child touches the toy but does not pick it up. The caregiver picks up the toy and places it in the eyesight of the caregiver picks up the toy and places it in the eyesight of the baby. “Do you want to play with this toy? I do you want to see baby. “Do you want to play with this toy? I do you want to see what the toy can do?” The caregiver pushes the toy and the toy what the toy can do?” The caregiver pushes the toy and the toy begins to light up. The child is interested and reaches for the toy. begins to light up. The child is interested and reaches for the toy. “Do you know what the toy can do? The toy can light up. Can you “Do you know what the toy can do? The toy can light up. Can you push the button on the toy?” The baby babbles some more and push the button on the toy?” The baby babbles some more and puts the toy in their mouth. The caregiver pulls the toy out and puts the toy in their mouth. The caregiver pulls the toy out and places it on the blanket. The baby reaches for it again and while places it on the blanket. The baby reaches for it again and while doing so pushes the button and the toy lights up. “Very good! You doing so pushes the button and the toy lights up. “Very good! You made the toy light up. Can you do that again?” The toy is placed made the toy light up. Can you do that again?” The toy is placed on the blanket and the baby reaches for it and touches the button. on the blanket and the baby reaches for it and touches the button. The caregiver gives praise to the child and the child slaps his The caregiver gives praise to the child and the child slaps his hands on his legs and smiles.hands on his legs and smiles.

Incidental Teaching…Incidental Teaching… What is it: Provides structured learning What is it: Provides structured learning

experiences in everyday activities and experiences in everyday activities and natural environments.natural environments.

Goal: Designed to increase language and Goal: Designed to increase language and social responses by using positive social responses by using positive reinforcement and by following child’s reinforcement and by following child’s interests.interests.

What it looks like…What it looks like… Must be preplanned- (ex. Going to the Must be preplanned- (ex. Going to the

store, zoo, mall, restaurant, special toys, store, zoo, mall, restaurant, special toys, activity ect.)activity ect.)

Have objectives-(ex. Today I will establish Have objectives-(ex. Today I will establish 3-4 teachable moments and use them to 3-4 teachable moments and use them to work on Johnny giving me two word work on Johnny giving me two word responses.)responses.)

Elaborate- “motherese” support the child Elaborate- “motherese” support the child to give more of a response. to give more of a response.

Elaboration: Level of Elaboration: Level of prompts …prompts …

Prompts to help make the child successful:Prompts to help make the child successful: Level 1: This prompt involves waiting 30 sec. when a child Level 1: This prompt involves waiting 30 sec. when a child

shows an interest in an object ect. This delay is to encourage the shows an interest in an object ect. This delay is to encourage the student to give some kind of initiative towards the object. student to give some kind of initiative towards the object.

Level 2: After 30 sec., if the child has not asked for the item, Level 2: After 30 sec., if the child has not asked for the item, then prompt the child appropriately ex. What do you want?then prompt the child appropriately ex. What do you want?

Level 3: If the child still does not respond, provide the student Level 3: If the child still does not respond, provide the student with a more specific prompt with gestures ect. Ex. What is that?with a more specific prompt with gestures ect. Ex. What is that?

Level 4: This is the most supported level. Prompt the child to Level 4: This is the most supported level. Prompt the child to imitate the correct response that is being modeled for the child. imitate the correct response that is being modeled for the child. Ex. That is the car. I want the red car.Ex. That is the car. I want the red car.

The goal is to use the least amount of prompts to get the student to The goal is to use the least amount of prompts to get the student to respond correctly.respond correctly.

Example of Incidental Example of Incidental TeachingTeaching Johnny wants the fish crackers. He is trying to Johnny wants the fish crackers. He is trying to

pull them off the counter. The teacher sees this pull them off the counter. The teacher sees this and walks over. Johnny looks at the teacher. and walks over. Johnny looks at the teacher. The teacher waits 30 sec. The child does not The teacher waits 30 sec. The child does not respond. “Johnny, what do you want?” the respond. “Johnny, what do you want?” the teacher asks. Johnny points to the crackers. teacher asks. Johnny points to the crackers. “What is that?” The child still does not respond. “What is that?” The child still does not respond. “Johnny, you want the orange fish crackers?” “Johnny, you want the orange fish crackers?” Show the child the crackers and prompt the Show the child the crackers and prompt the student to model “ I want crackers.”student to model “ I want crackers.”

TEACCHTEACCH What is it: The Treatment and Education of Autistic and What is it: The Treatment and Education of Autistic and

related Communication handicapped Children is a division related Communication handicapped Children is a division of the Dept. of Psychiatry of the School of Medicine at the of the Dept. of Psychiatry of the School of Medicine at the University of North Carolina at Chapel Hill.University of North Carolina at Chapel Hill.

Provides evaluations, individualized curriculum, social skill Provides evaluations, individualized curriculum, social skill training, vocational training, parent counseling and training, vocational training, parent counseling and training.training.

Goal: To develop individual plans to help people with Goal: To develop individual plans to help people with autism and their families to live together more effectively autism and their families to live together more effectively by decreasing the autistic like tendencies that limit the by decreasing the autistic like tendencies that limit the quality of life.quality of life.

Parts of their curriculum have been copied.Parts of their curriculum have been copied.

What TEACCH looks like….What TEACCH looks like…. Emphasis placed on individual needs, goals, curriculum and classroom are Emphasis placed on individual needs, goals, curriculum and classroom are

made for that child to reduce autistic tendenciesmade for that child to reduce autistic tendencies Well organized space, designated areas, labels, ect.Well organized space, designated areas, labels, ect.

Color coding: for each child, or materials, or areas of the roomColor coding: for each child, or materials, or areas of the room Use pictures: child’s place, destination, daily schedule, reminders or desired Use pictures: child’s place, destination, daily schedule, reminders or desired

behaviors, where things belong, tasks and activitiesbehaviors, where things belong, tasks and activities Lists: what to take home, bring back to school, what to get, what needs to be Lists: what to take home, bring back to school, what to get, what needs to be

completed, various jobs in the classroom ect.completed, various jobs in the classroom ect. Colored tape: transition paths, line up places, personal spaceColored tape: transition paths, line up places, personal space Dividers: personal space, comfort, to mask stimuli, provide as obstacles for running Dividers: personal space, comfort, to mask stimuli, provide as obstacles for running

awayaway

Schedules posted (written, PECS, icons)Schedules posted (written, PECS, icons) Direct instruction: Directions need to be given with prompts, pictures, visual Direct instruction: Directions need to be given with prompts, pictures, visual

cues, hand movements (sign language)cues, hand movements (sign language) Well organizedWell organized Repeat and reviewRepeat and review Positive reinforcementPositive reinforcement

Social StoriesSocial Stories

What is it: Short stories that explain common What is it: Short stories that explain common occurrences with matching social cues and occurrences with matching social cues and what and why the situation happens.what and why the situation happens.

Goal: These stories are designed to prepare an Goal: These stories are designed to prepare an individual with information, strategies and a individual with information, strategies and a well thought out process of how to deal well thought out process of how to deal effectively with an event.effectively with an event.

Gray, C. (1993). Social stories:Gray, C. (1993). Social stories:Improving responses of students with autism with accurate social information. Improving responses of students with autism with accurate social information. Focus on Autistic Behavior, 8,Focus on Autistic Behavior, 8, 1- 1-10.10.

Gray, C. (1996). Teaching children with autism to "read" social situations. In K. Quill (Ed.), Gray, C. (1996). Teaching children with autism to "read" social situations. In K. Quill (Ed.), Teaching students Teaching students with autism: Methods to enhance learning, communication, and socializationwith autism: Methods to enhance learning, communication, and socialization (pp. 219-242). New York, NY: (pp. 219-242). New York, NY: Delmar Publishers.Delmar Publishers.

What it looks like…What it looks like…

Describes where the situation occurs, who is Describes where the situation occurs, who is involved, what they are doing and why, how involved, what they are doing and why, how they feel and how they react.they feel and how they react.

Provides sequential steps for an everyday Provides sequential steps for an everyday event and how to accomplish it.event and how to accomplish it.

The desired behavior is clear and stated in The desired behavior is clear and stated in positive ways by the characters in the storypositive ways by the characters in the story

Describes ways to help the child remember the Describes ways to help the child remember the social story and how to work through that social story and how to work through that particular event.particular event.

How it is used…How it is used…

1.1. Select a behavior that would increase a Select a behavior that would increase a positive social interaction for that child.positive social interaction for that child.

2.2. Match a social story with the target behavior.Match a social story with the target behavior.

3.3. Help the child generalize the story across Help the child generalize the story across many situation with various activitiesmany situation with various activities

4.4. Reread the story Reread the story

5.5. Gradually fade the story out after the you Gradually fade the story out after the you have seen the child’s behavior changehave seen the child’s behavior change

Facilitating Reading Comprehension for Students on the Autism SpectrumSusan E. Gately

Children with Autism have difficulty with:Children with Autism have difficulty with: Reading comprehensionReading comprehension Poorer silent reading skillsPoorer silent reading skills InferencingInferencing Can decode well above age, but can not Can decode well above age, but can not

comprehend passage called Hyperlexiacomprehend passage called Hyperlexia Difficulty understanding setting (social Difficulty understanding setting (social

context), characters (actions, motives, goals, context), characters (actions, motives, goals, emotions)emotions)

Strategies to help with Strategies to help with Reading ComprehensionReading Comprehension

1.1. Build background knowledge and preteachBuild background knowledge and preteach2.2. Picture WalksPicture Walks3.3. Graphic OrganizersGraphic Organizers4.4. Think alouds, reciprocal thinkingThink alouds, reciprocal thinking5.5. Preteach narrative text structurePreteach narrative text structure6.6. Goal structure mapping (who, did what)Goal structure mapping (who, did what)7.7. Emotional thermometersEmotional thermometers8.8. Social StoriesSocial Stories

Gately, Susan (2008).Facilitating Reading Comprehension Gately, Susan (2008).Facilitating Reading Comprehension for Students on the. for Students on the. Teaching Exceptional ChildrenTeaching Exceptional Children. . 4040, 40-, 40-45. 45.

References and References and ResourcesResources http://www.autismeducation.net/diagnosing.htm

(evaluations)(evaluations) http://www.centerforautism.com/aba/whatisaba.asp

(ABA)(ABA) http://autism.healingthresholds.com/therapy/sensory-int

egration (SI) (SI)

http://www.mcesa.k12.mi.us/AutismTips.htm Gately, Susan (2008).Facilitating Reading Gately, Susan (2008).Facilitating Reading

Comprehension for Students on the. Comprehension for Students on the. Teaching Teaching Exceptional ChildrenExceptional Children. . 4040, 40-45. , 40-45.

Easterbrooks, S, & Handley, C.M. (2005-06). Behavior Easterbrooks, S, & Handley, C.M. (2005-06). Behavior Change in A Student with a Dual Diagnosis of Change in A Student with a Dual Diagnosis of Deafness and Pervasive Developmental Disorder: A Deafness and Pervasive Developmental Disorder: A Case Study. Case Study. American Annuals of the DeafAmerican Annuals of the Deaf. . 150150, 401-, 401-407. 407.