NONVERBAL PATIENTS

Open Page In New Window(Print/Link)

Introduction
Using Nonverbal Communication
Recognizing Medical Conditions
References
Resources for Families
Publication Information

Learning Points
back to top

• Confirm that delayed or deficient development of language is a common symptom of many developmental disabilities, including mental retardation, cerebral palsy, autism, communication disorders, hearing impairment, and hydrocephalus.
• Recognize that patients with speech or language difficulties should be referred for consultation by a speech and language pathologist for an individualized speech and language therapy program.
• Differentiate between a speech disorder (deficits or abnormalities in producing certain speech sounds) and a language disorder (deficits in using appropriate words and forming sentences; impaired comprehension of language).
• Restate the rationale for referring a patient with elective mutism to a psychiatrist (because psychotherapy and behavior modification may be helpful).
• Acknowledge that hearing impairment may be a cause of communication deficits and refer to an audiologist if hearing impairment is suspected.
• List the four types of nonverbal communication that can be used to communicate with a patient who uses limited verbal communication; e.g.,
• Universal language
• Picture communication
• Computer-assisted intervention
• American Sign Language
• Recognize that general pain and/or discomfort may be manifested as a high activity level, rocking, head-banging, or other behavioral presentation.
• List four possible conditions causing a change in the level of consciousness; e.g.,
  • Bowel obstruction
  • Head injury
  • Hydrocephalus
  • Medication reaction
• Delineate three possible conditions that could account for breathing difficulty; e.g.,
  • Aspiration with chemical pneumonia
  • Asthma
  • Bowel obstruction
• List three possible conditions that could account for unusual or recurrent masturbation; e.g.,
  • Urinary tract infection
  • Candida vaginitis
  • Pinworms
• Refer families to appropriate resources.

INTRODUCTION
back to top

Delayed or deficient development of language is a common symptom of many developmental disabilities, including mental retardation, cerebral palsy, autism, communication disorders, hearing impairment, and hydrocephalus. Patients with speech or language difficulties should be referred for consultation by a speech and language pathologist for an individualized speech and language therapy program. The speech and language pathologist can also help train physicians, nurses, and parents/caregivers to communicate more effectively with the patient.

Types of Communication Disorders

The spectrum of speech and language deficits ranges from mild speech deficits to severe communication disorders that affect both expressive and receptive language. The four basic categories of communication disorders are:

• Speech disorders: deficits or abnormalities in producing certain speech sounds
• Motor speech disorders: abnormal articulation of speech sounds
• Language delay: delayed development of expressive and/or receptive language
• Language disorders: deficits in using appropriate words and forming sentences; impaired comprehension of language

Elective mutism refers to people (usually children aged 3 to 5) who have the ability to speak and use language effectively, but who refuse to talk under certain circumstances or will only talk to certain individuals. Referral to a psychiatrist is warranted in this situation because psychotherapy and behavior modification may be helpful.

Hearing impairment may also be the cause of communication deficits. Referral to an audiologist is warranted if hearing impairment is suspected based on observation of the patient or concerns communicated by parents/caregivers. In addition, it is important that any child with delayed or abnormal speech and language development undergo objective audiological testing in order to rule out even mild to moderate bilateral or unilateral hearing loss, which can have significant adverse effects on language development, communication skills, and social skills.

USING NONVERBAL COMMUNICATIONS
back to top

Primary care physicians may need to rely on nonverbal methods of communication in order to diagnose, treat, and follow-up on medical conditions in patients who are unable or unwilling to communicate verbally. It is important to be confident when working with nonverbal patients, as alternate forms of communication are often very effective and easy to use. It is also important to help parents and caregivers learn how to use alternate forms of communication.

It may be important to manipulate the arrangement of visual information, the setting, or the teaching techniques in order to:

• Develop communication skills;
• Increase responsiveness to instruction;
• Overcome problems such as overselective attention to certain stimuli; and
• Reduce excessive dependence on prompts.

Communication methods should be tailored to the individual's learning style, which often includes a combination of visual and auditory inputs. The primary physician may consider referring a nonverbal patient for evaluation by a speech and language pathologist with expertise in augmentative communication in order to ascertain which system would be most appropriate.

Forms of Nonverbal Communication

The following are examples of ways to communicate with a patient who uses limited verbal communication. Impaired cognitive skills may prevent some patients from using these forms of communication.

Universal language

Clinicians and patients may use gestures, facial expressions, objects or pictures to communicate simple choices. Using the context of the environment may assist with comprehension.

Picture communication

The patient points to pictures, symbols, or words on a flat communication board. There are also electronic communication boards available, often with voice synthesizers.

Computer-assisted intervention

Computers make highly individualized intervention programs more possible. For example, computers can alter the rate, loudness, and pitch of sounds based on individual needs. Some patients may also be able to use typewriters or tape recorders to better express themselves.

American Sign Language

Some patients may not be able to learn this language, and clinicians cannot be expected to be fluent; however, knowing a few functional signs is usually possible for both. For example, it may be possible to learn how to signal pain, discomfort, hunger, thirst, etc.

RECOGNIZING MEDICAL CONDITIONS
back to top

When a patient cannot speak or otherwise communicate effectively, it becomes essential for physicians to focus on the patient's behavior when making a diagnostic formulation. In persons with developmental disabilities, specific behaviors can sometimes be clues to medical or psychiatric conditions [Return to the index for a complete document on Psychiatric Co-morbidity]. In general, localizing signs or symptoms suggest local disease. For example, walking with a limp suggests pathology in one leg while inability to walk suggests unrelated pathology in both legs (an unlikely occurrence) or systemic illness involving the peripheral nervous system, the central nervous system, the vascular system, or other organ system. As a result, the presence of localizing signs and symptoms should lead to careful evaluation of the area.

In people with developmental disabilities, many serious clinical problems do not present with localized findings until the course of the problem is well advanced; instead, constitutional signs or symptoms are present. In most cases, the specific etiology can be determined through a detailed review of the history of the present illness, a careful review of systems, and a thorough physical examination with appropriate diagnostic testing. On rare occasions, however, these strategies will be unsuccessful and the underlying diagnosis will escape detection. In these instances, there are two general approaches. First, if the level of distress is not great and there appears to be no life-threatening illness, the physician may choose to manage the problem expectantly.

Second, if the symptoms are more significant or there is concern over the presence of a life-threatening illness, it would be prudent to undertake additional testing. Additional testing should be guided by knowledge about the prevalence of specific conditions associated with developmental disabilities.

Below is a list of specific symptoms and underlying conditions that may be related. While the list is not exhaustive, it is intended to guide additional evaluation for the patient who presents with non-specific or constitutional symptoms. Keep in mind that the same symptom in the same person can mean something different at different times.

General pain/discomfort which may be manifest as a high activity level, rocking, head-banging, or other behavioral presentation

• Arthritis
• Bone fracture
• Cardiac disease
• Cervical body subluxation
• Constipation
• Dehydration
• Dental pathology
• Electrolyte or glucose abnormality
• Gastroesophageal reflux (with or without esophagitis)
• Headache or migraine
• Hernia
• Hydrocephalus
• Intestinal obstruction
• Medication toxicity
• Occult infection (sinusitis, otitis media, dental, urinary tract infection, vaginitis, prostatitis)
• Ocular and vision problems
• Pneumonia
• Psychiatric disorders including depression
• Rectal fissure
• Seizures
• Sepsis
• Trauma including abuse or neglect

Change in level of consciousness

• Bowel obstruction
• Head injury
• Hydrocephalus
• Medication reaction
• Metabolic condition
• Pneumonia
• Seizures
• Sepsis
• Stroke
• Hypoxia

Breathing difficulty

• Aspiration with chemical pneumonitis
• Asthma
• Bowel obstruction
• Congestive heart failure
• Foreign body in lungs
• Pneumonia
• Sepsis
• Reflux
• Obstructive apnea

Sudden sitting

• Atlanto-axial dislocation
• Cardiac problems
• Seizures
• Syncope or orthostasis
• Vertigo

Unwillingness to sit or uneven sitting

• Akathisia
• Back pain
• Genital discomfort
• Hip pain
• Psychiatric disorders including anxiety
• Rectal, vaginal, or prostate discomfort

Hand or fingers in mouth

• Asthma
• Dental pathology
• Eustachian tube/middle ear problem
• Gastroesophageal reflux
• Nausea
• Sinus problem

General scratching

• Atopic dermatitis
• Eczema
• Pancreatitis, liver and gall bladder disease
• Medication side effects
• Renal disorder
• Scabies

Unusual or recurrent masturbation

• Prostatitis
• Urinary tract infection
• Candida vaginitis
• Pinworms

Pica

• Hypothalamic problems
• Psychiatric disorders
• History of understimulating environments
• Iron deficiency
• Lead poisoning

REFERENCES
back to top

Peer-reviewed Journal Articles/Academies

Kastner, T., Walsh, K. (1999). Challenging Behavior Problems in Children with Mental Retardation. In: Developmental and Behavioral Pediatrics. (Eds.) Parker and Zuckerman. Little Brown.

Kastner, T,. Walsh, K,. Fraser, M. (2001). Undiagnosed Medical Conditions and Medication Side Effects Presenting as Behavioral/Psychiatric Problems Among People with Mental Retardation. Mental Health Aspects of Developmental Disabilities 4(3). 101-108.

McGrath, PJ, et al. (1998). Behaviours Caregivers Use to Determine Pain in Non-verbal, Cognitively Impaired Individuals. Developmental Medicine and Child Neurology, 40(5), 340-343.

The Mental Retardation and Developmental Disabilities Branch: Report to the NACHHD Council. (1997). National Institute of Child Health and Human Development.

Special Interest Groups/Other Publications

Batshaw, M.L., Perret, Y.M., Bleile, K., (1992). Children with Disabilities. Baltimore: Paul H. Brookes Publishing., pp. 351-364.

Capute, A.J., P.J. Accardo. (1991). Developmental Disabilities in Infancy and Childhood. Baltimore: Paul H. Brookes Publishing., pp. 175-179.

Panacha, R. (1996). Pediatric Traumatic Brain Injury. In A.J. Capute & P.J. Accardo (2nd ed.), Developmental Disabilities in Infancy and Childhood (pp.337-346). Baltimore: Paul H. Brookes Publishing Co.

Ryan, R., et al. (1997). Nonverbal Complaints/ Clues (handout from Whole Person Assessment Seminar) (June).

Smith Consultant Group and McGowan Consultants. (1998). (Ed.) M.L Snyder, Signs and Symptoms of Illness. Health and Wellness Reference Guide. Neri Productions, State of Tennessee Commission on Compliance , pp. 117-121.

Wang, P., Baron, M.A. (1996). Language: A Code for Communicating In A.J. Capute & P.J. Accardo (2nd ed.), Developmental Disabilities in Infancy and Childhood (pp.621-642). Baltimore: Paul H. Brookes Publishing.

Wardinsky, T. (1998). Training Manual on Medical Needs of Individuals with Developmental Disabilities. Alta California Regional Center, 1997-1998 Wellness Project.

RESOURCES FOR FAMILIES
back to top

American Speech-Language-Hearing Association
800-638-8255

The Arc
800-433-5255

California Department of Developmental Services
916-654-1690

California Regional Centers
915-654-1958

California Speech-Language-Hearing Association
916-921-1568

Exceptional Parent Magazine
800-247-8080

March of Dimes Birth Defects Foundation
914-428-7100

National Institute on Deafness and Other Communication Disorders
301-496-7243

PUBLICATION INFORMATION
back to top

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services.

This document is available at www.ddhealthinfo.org

Last updated July 1, 2008