Compelled by the need for mental health services in schools for deaf children and adolescents, Annie Steinberg, M.D., a member of APA's Deaf Caucus, established what is believed to be the first school-based mental health program for deaf children in Philadelphia County in 1992.

"We were receiving so many calls from the community and from schools for the deaf requesting services that we conducted a survey of two schools in Philadelphia County. The findings showed that 40 percent of the children had unmet mental health and case management needs," according to Steinberg.

Steinberg and a family therapist meet regularly with staff at the Pennsylvania School for the Deaf for children ages 2 to 15, and together lead individual and family sessions as well as sessions for groups of students. "Children and adolescents are extremely responsive to group interventions with peers and/or group leaders who are deaf," noted Steinberg.

The school-based partnership has "dramatically improved the accessibility and quality of mental health services available to deaf children and their families," said Steinberg. Other benefits are increased cost-effectiveness and collaboration between school staff and families, and reduced isolation among professionals in deafness- related fields, noted Steinberg.

Establishing school-based mental health programs is just one of many services offered by the Deafness and Family Communication Center founded by Steinberg and a family therapist in 1992 at the University of Pennsylvania Medical Center. Other services include training for professionals and conducting research on the impact of deafness on the mental health of children, adolescents, and families.

Deafness or hearing loss affects an estimated one million children and adolescents.

Steinberg estimated that 10 APA members including herself work primarily with individuals who are deaf, as indicated by a directory compiled by APA's Deaf Caucus. Several other APA members work part time with deaf or hearing impaired patients.

Joan Kinlan, M.D., a consultant to schools for the deaf in Washington, D.C., and a corresponding member of APA's Committee on Psychiatry and Mental Health in the Schools, is involved in the committee's project on consultation activities for deaf children and adolescents (see story below).

Kinlan described how she became a consultant. "I became intrigued with working with deaf children almost 20 years ago when I was asked to evaluate a young child with behavioral problems whom the school staff presented as their worst case. Although I didn't know sign language then, the child dramatically improved with simple behavioral techniques that I had been trained in."

Since then, Kinlan has taken sign language courses at Gallaudet University in Washington, D.C. She has been a longtime consultant to the university and sees students in her private practice. She consults at the Model Secondary School for the Deaf (MSSD), also in Washington, D.C.

Like Steinberg, she works closely with school counselors and educators. Her weekly consultation at MSSD includes psychiatric evaluations, reviewing cases with staff, and developing individual treatment plans.

She emphasized the importance of conducting a careful diagnostic evaluation and using referrals because at least one-third of deaf children also have physical or neurological injuries. The damage is associated with meningitis and perinatal infections, two of the leading causes of deafness. They can contribute to ADHD, learning disabilities, and problems with motor coordination, according to Steinberg.

Kinlan prefers to sign and speak simultaneously with her deaf patients, a method she referred to as "total communication." However, when communicating with deaf counselors who only sign or don't speak, she uses an interpreter who is fluent in ASL. ASL is the accepted form of communication among the deaf.

"Some words can be signed 50 different ways, and there are a lot of gestures and body language in ASL. I don't want to miss any of the nuances," explained Kinlan.

Steinberg has studied ASL extensively and is participating in a project to determine whether the standardized Diagnostic Interview Schedule (DIS) can be translated "into any modality a deaf person might choose including ASL, signed English, and oral interpreted with captions." She explained that ASL is a highly visual language that is different structurally from English, rendering standard diagnostic instruments inaccessible to individuals who are deaf.

Besides learning ASL, Kinlan and Steinberg have also familiarized themselves with the deaf culture and local deaf community. Steinberg noted that membership does not relate to the degree of hearing loss as much as the ability to identify with the deaf culture and share language. For example, some in the deaf community capitalize the word deaf, as a way of distinguishing themselves, noted Steinberg.

The deaf pride movement in the last decade has resulted in greater advocacy and the view among many deaf people that deafness is not a handicap, said Kinlan.

Because of these trends, some in the deaf community oppose cochlear implants." Implants may give some people an edge, for example, in traffic, but they do not restore hearing to normal," said Kinlan.

A longstanding controversy has been whether educators and parents should use oral methods, manual methods including ASL, or both with deaf or hard-of-hearing children.

Because of research by Katherine Meadow-Orlans, Ph.D., a sociologist at Gallaudet University, and others, Kinlan encourages hearing parents of deaf children to learn to sign early with their children rather than communicate only orally. She found that deaf children in residential schools in California were three times more likely to have behavioral problems than hearing children in public schools. She commented that the higher incidence of "impulsive acting-out behaviors resulted from resentment over their inability to communicate linguistically."

Meadow-Orlans noted that oral communication was the only method used in the classroom several years ago, requiring children to lip-read.

She cited another study she conducted finding that deaf children of deaf parents "did better academically and were better adjusted" because they were exposed to manual communication methods. "As a result of these findings, educators began to look at total communication," she said.

Steinberg, who noted working with Meadow-Orlans on several research projects, said, "Emotional problems in children who are deaf tend to be multifactorial and not just the result of communication issues."

Preliminary findings of Steinberg's recent study of behavioral problems in deaf children suggest that "referrals for mental health counseling correlate significantly with aggressive and disruptive behaviors, a history of physical and sexual abuse, the late initiation of signing, and acquired deafness," said Steinberg.

"Late signing may also relate to the child's late diagnosis of deafness rather than solely a lack of parental signing," commented Steinberg.

She observed that there is professional bias toward parental signing and against the use of oral methods. She cautioned psychiatrists against falling into the trap of "the either-or phenomena."

"Our longitudinal study on parental decision making after the identification of deafness suggests that parents choose communication methods based on the goals they have for their deaf children. For example, the oral method might give them greater potential to live and work solely in the hearing world. The manual method may provide greater access and opportunities to socialize with their deaf peers," said Steinberg.

She referred to several other research projects on deafness and mental health she is conducting. More information is available by calling the Center for Deafness and Family Communication at (215) 243-2756; Web site: <.http:\\www.med. upenn./ edu~dfcc>.

More information about the activities of APA's Deaf Caucus is available by calling Barbara Haskins, M.D. at (703) 332-8152.

Do You Work With Deaf Children?

APA's Committee on Psychiatry and Mental Health in the Schools has initiated a project to increase awareness of psychiatric consultation with deaf and hearing-impaired children and adolescents.

The committee's initial step will be compiling a national directory of psychiatrists with expertise in American Sign Language (ASL) and familiarity with the deaf culture.

Committee Chair David Fassler, M.D., observed that there is a paucity of psychiatrists fluent in ASL, and locating the few who are can be difficult.

Joan Kinlan, M.D., a corresponding member to the committee and a consultant to Washington, D.C., schools for the deaf, commented that the directory will also facilitate communication among psychiatrists working with this population. "If we encounter a tough case, we can call each other up to discuss it."

The committee plans to collaborate on this project with organizations such as the National Association for the Deaf. The directory will be distributed to state medical societies, and discussions are under way about making the directory available on APA's Web site.

Fassler observed that psychiatrists including himself generally have limited training and expertise in working with the deaf. Seeking outside education and consultation becomes necessary.

He referred to his experience working with deaf and hearing-impaired children as a consultant for the Vermont Department of Health. "I was impressed with the multifaceted evaluation of the children and families conducted by a team that included a pediatrician, an audiologist, and a special consultant hired by the state to educate the clinicians about deaf culture."

Psychiatrists who wish to be included in the committee's directory should write David Fassler, M.D., Committee on Psychiatry and Mental Health in the Schools, APA, 1000 Wilson Boulevard, Arlington, Va. 22209-3901.

Future committee efforts include an annual meeting workshop and a monograph series on issues related to working with the deaf.

(Psychiatric News, November 1, 1996)