Definitions of disabilities categorized as low-incidence vary in scope. Broadly defined, low-incidence disabilities refer to a visual impairment or hearing loss, deaf-blindness, and significant cognitive impairment. For children, the definition extends to any impairment that requires individualized intervention services provided by professionals with highly specialized skills and knowledge in order for the child to benefit from his or her education. Thus, this definition includes individuals with autism, traumatic brain injuries, orthopedic impairments, or multiple disabilities. Although these classifications may be useful for data collection or communicating potential needs of clients with a particular disability, individuals within each disability category may be more different than they are alike and will likely require highly individualized services.
Even when a very broad definition is used, individuals with low-incidence disabilities compose a small percentage of the population. Nevertheless, it is likely that counselors will encounter clients with low-incidence disabilities in their practice. Individuals with disabilities, like all individuals, may present with a variety of physical, social, and psychological needs that may warrant professional intervention. In keeping with ethical standards, professionals should practice within the scope of their training and recognize when it may be more appropriate to refer to a practitioner with specialized training in the area of the client’s disability.
This entry focuses primarily on issues related to providing services to individuals with visual impairments, deaf-blindness, and hearing loss.
Understanding Low-Incidence Disabilities
Deaf/Hard of Hearing
Within the medical field, hearing loss is typically defined by one’s ability to perceive sounds of different frequencies and at different intensities. Hearing loss is classified as normal (0-15 decibel [dB] loss), mild (26-10 dB loss), moderate (41-70 dB), severe (71-90 dB), or profound (91dB or greater). In addition, hearing losses may be classified as conductive, sensorineural, mixed, or central auditory processing disorders. Hearing loss can also be defined by functional ability. For example, individuals who are able to communicate using the telephone are often considered “hard of hearing,” while those who primarily receive information visually rather than through auditory pathways are considered “deaf.” These medical and functional definitions do not necessarily correspond with an individual’s cultural identity. Some clients who have a hearing loss may consider themselves culturally Deaf (indicated with the capital D), reflecting their pride in belonging to a community of individuals that share common experiences, a rich cultural heritage, and a shared language—sign language.
The deaf and hard of hearing population is het-erogenous. Factors to consider when working with an individual who is deaf or hard of hearing include the cause, type, severity, and stability of hearing loss; age of onset; type of amplification preferred; preferred communication modality; presence of any additional disabilities; and cultural affiliation. The unique interplay of these factors differentially impacts the individual’s language development, speech intelligibility, academic performance, self-concept, identity, behavior, and social and emotional development.
Definitions of visual impairment vary but often refer to levels of visual acuity or functioning. Clarity of vision is typically defined in terms of visual acuity, measured on a scale comparing the person’s vision at 20 feet with that of someone who has full acuity. Visual acuity ranges from normal vision (20/20 acuity) to profound low vision acuity (lower than 20/400). Visual acuity that approximates total blindness may also be designated by functional descriptions such as the ability to detect light. The term blindness typically refers to total vision loss, including no light perception, or significant impairment in sight, making it necessary for the individual to rely primarily on senses other than vision to interact with the environment. Legal blindness does not necessarily imply total blindness, and it is defined as corrected distance visual acuity of less than 20/200 or a visual field of 20 degrees or less in the better eye. Individuals with visual impairments demonstrate a wide range of vision functioning that may fluctuate on a daily basis due to a variety of factors.
Factors contributing to the uniqueness of each individual with a vision loss include the type, severity, etiology, age of onset, and stability of the vision impairment as well as the presence of one or more developmental disabilities.
Individuals who are considered deaf-blind have co-occurring vision and hearing losses. The vision and hearing loss both may have been present from birth, or one may precede the other. Often, vision and/or hearing may decline throughout the individual’s lifetime. Clients fitting this classification likely have significant impairments in vision and hearing, requiring specialized services that are not adequately defined by typical services for individuals who are either deaf or blind. Vision and hearing functioning vary considerably within this population, resulting in varied communication preferences and use of assistive devices. Thus, factors contributing to the uniqueness of individuals who are deaf-blind include the etiology, age of onset, severity of visual and hearing impairment, communication preferences, and presence of comorbid disabilities.
The mental health needs of individuals with low-incidence disabilities have been traditionally under-served. Historically, counselors’ misunderstandings about individuals with disabilities often led to erroneous assumptions that clients with significant hearing and/or vision loss lacked the language and cognitive skills necessary to benefit from therapy. Clients with disabilities who continually encounter bias in their everyday lives may be resistant to or distrustful of counselors who they do not feel relate to their experience. Furthermore, limited accessibility to services continues to be influenced by the shortage of professionals trained to meet the unique needs of these clients. In particular, there is a scarcity of practitioners who can communicate directly with clients using sign language.
Because of the importance of communication in therapy, it is critical for counselors to attempt to match the client’s preferred mode of communication. Clients who are deaf, hard of hearing, or deaf-blind may prefer to communicate using speech, American Sign Language or other sign language systems, cued speech, gestures, pantomime, body language and facial expressions, writing, or combinations of the above. Communicating directly with clients in their preferred mode of communication is preferable to facilitate the therapeutic process. However, when direct communication is not possible, counselors may have to rely on using interpreters. Counselors should be aware of the impact of indirect communication on the therapeutic relationship with their client, including the client’s level of trust and confidence in the counselor, the increased likelihood of miscommunication, and challenges in effectively assessing the client’s language level and thought process. When interpreters must be used, it is preferable to use a consistent, certified interpreter.
A developmental perspective is also important when working with clients with low-incidence disabilities. For example, young children with visual impairments will need support to learn how to explore and function independently within their environment. Severe visual impairment may affect children’s social skills. They may need to be directly taught skills for using meaning-hil gestures and appropriate facial expressions, joining in sports and other social activities, assertiveness, and self-advocacy. Children with congenital blindness may also demonstrate behaviors that appear to be autistic (e.g., echolalia, stereotypic behaviors), which may also interfere with socialization.
Language delays associated with hearing loss may also significantly affect one’s behavioral regulation and social skills throughout the life span. Children with hearing loss may feel isolated from peers who do not use the same communication modality. Adapting to their hearing and/or vision loss may have a significant impact on individuals’ developing sense of identity and willingness to assert their independence. Individuals coping with sudden or progressive vision and/or hearing loss may benefit from counseling as they adjust to resulting changes. Even those who have seemingly adjusted to the impact of their vision loss may re-experience social and emotional adjustment difficulties when faced with particular developmental milestones impacted by their visual impairment, such as getting a driver’s license or transitioning to college or the workplace.
When working with clients with low-incidence disabilities, it is important for counselors to consider the match between the client and his or her environment, given each client’s unique characteristics and needs. It may be particularly important to include families in counseling. Much like individuals reacting to progressive vision or hearing loss, parents go through a process similar to grieving in reaction to their child’s diagnosis. Particularly when the diagnosis is made during early childhood, parents’ attachment and parenting skills may be affected. The overwhelming majority of children who are deaf are born to hearing parents. This results in a unique situation in which the child may communicate using a language that differs from his or her parents’ language and may identify with a culture that differs from his or her parents’ hearing culture. Furthermore, an individual’s declining vision and/or hearing functioning also likely has an impact on the family. It may be beneficial to include other family members in treatment to address changes in roles and responsibilities and associated stress on the family unit.
Role of the Counselor
Counselors fill a variety of roles working with clients with low-incidence disabilities. Rehabilitation counselors evaluate and address clients’ independent living skills, use of assistive devices, social interaction skills, academic or career skills, and recreation and leisure skills. An assessment of language and communication functioning or orientation and mobility skills may also be warranted.
Professionals conducting assessments with individuals with low-incidence disabilities should refer to professional guidelines regarding appropriate assessment procedures. Assessment tools must be selected carefully with the understanding that few instruments allow comparisons with other individuals demonstrating similar disabilities. When working with clients with visual impairments, clinicians should avoid tasks that place heavy demands on vision, including verbal tasks with a corresponding visual component, unless the purpose of the assessment is to measure vision. Conversely, when working with clients with hearing loss, nonverbal, performance-based tasks may yield the best estimate of functioning. It may be appropriate to provide accommodations during the assessment that facilitate the client’s access to the tasks without significantly altering the construct intended to be measured. One should also take into consideration whether the assessment reflects experiences that may be outside of the client’s repertoire due to the impact of the vision or hearing loss. Finally, the impact of vision or hearing loss on processing speed, concentration, attention, and fatigue should be carefully considered when interpreting results.
- Glickman, N. S., & Gulati, S. (Eds.). (2003). Mental health care of deaf people: A culturally affirmative approach. Mahwah, NJ: Lawrence Erlbaum.
- Ingraham, C. L., Carey, A., Vernon, M., & Berry, P. (1994). Deaf-blind clients and vocational rehabilitation: Practical guidelines for counselors. Journal of Visual Impairment and Blindness, 88(2), 117-127.
- Leigh, I. W. (Ed.). (1999). Psychotherapy with deaf clients from diverse groups. Washington, DC: Gallaudet University Press.
- Moore, J. E., Graves, W. H., & Patterson, J. B. (Eds.). (1997). Foundations of rehabilitation counseling with persons who are blind or visually impaired. New York: AFB.