Mental Health Assessment and Treatment

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Crump, C. J., & Hamerdinger, S. H. (2017). Understanding etiology of hearing loss as a contributor to language dysfluency and its impact on assessment and treatment of people who are deaf in mental health settings. Community Mental Health Journal.

Working with individuals who are deaf in mental health settings can be complex work, necessitating consideration for the difference in language abilities. These differences include not only variations in ASL and spoken language skills but various forms of language dysfluencies. This article discusses the many possible causes of language dysfluencies, highlighting not just language deprivation but medical etiologies which impact language development. Language dysfluency is discussed in terms of how it may impact psychiatric diagnosis. The authors refer to the detailed communication assessment done in the Alabama Office of Deaf Services and how it may guide clinicians and interpreters. This article contributes to the emerging discussion of language dysfluency patterns commonly seen in many deaf persons.

Fellinger, D., Holzinger, D., & Pollard, R. (2012). Mental health of deaf people. The Lancet, 379, 1037-1044.

Deafness is a heterogeneous condition with far-reaching effects on social, emotional, and cognitive development. Onset before language has been established happens in about seven per 10,000 people. Increased rates of mental health problems are reported in deaf people. Many regard themselves as members of a cultural minority who use sign language. In this review, the authors describe discrepancies between a high burden of common mental health disorders and barriers to health care. About a quarter of deaf individuals have additional disabilities and a high probability of complex mental health needs. Research into factors affecting mental health of deaf children shows that early access to effective communication with family members and peers is desirable. Improved access to health and mental health care can be achieved by provision of specialist services with professionals trained to directly communicate with deaf people and with sign language interpreters.

Glickman, N. (2009). Do you hear voices? Problems in assessment of mental status in Deaf persons with severe language deprivation. In N. Glickman, Cognitive behavioral therapy for Deaf and hearing persons with language and learning challenges (pp. 47-78). New York: Routledge.

When mental health clinicians perform mental status examinations, they examine the language patterns of patients because abnormal language patterns, sometimes referred to as “language dysfluency,” may indicate a thought disorder—a symptom of severe mental illness. Performing such examinations with deaf patients is a far more complex task, especially with traditionally underserved deaf people who have language deficits in their best language or communication modality. Many deaf patients suffer language deprivation due to late and inadequate exposure to ASL. They are also language dysfluent, but the language dysfluency is usually not due to mental illness. Others are language dysfluent due to brain disorders such as aphasia. This paper examines difficulties in performing a mental status examination with deaf patients. Issues involved in evaluating for hallucinations, delusions, and disorganized thinking are reviewed. Guidelines are drawn for differential diagnosis of language dysfluency related to thought disorder vs. language dysfluency related to language deprivation. This book chapter also includes a discussion of work with certified Deaf interpreters, the difficulty of interpreting abstract concepts, and examples of hearing psychologists drawing wrong conclusions because they weren’t aware of differences between ASL and English. Reference is also made to strategies for interpreting dysfluent language developed at the Deaf Wellness Center in Rochester, New York.

Gulati, S. (2003). Psychiatric care of culturally Deaf people. In N. Glickman & S. Gulati, Mental health care of Deaf people: A culturally affirmative approach (33-108). New York: Lawrence Earlbaum Associates.

This book chapter presents one of the first discussions of the relationship between language deprivation and psychiatric disorders. It presents a lot of general information designed to orient mental health professionals unfamiliar with deaf people to the special considerations involved in their psychiatric care. Dr. Gulati then describes the syndrome of language deprivation with clinical presentations and case examples. He describes common characteristics and behaviors of persons with varying degrees of language deprivation. Dr. Gulati also presents guidelines for clinical responses to persons with this syndrome.

Morgan, G., Herman, R., & Woll, B. (2007). Language impairments in sign language: Breakthroughs and puzzles. International Journal of Language and Communication Science, 42(1), 97-105.

Specific language impairment has previously solely been documented for children acquiring spoken languages, despite informal reports of deaf children with possible sign language disorder. The paper reports the case of a deaf child exposed to British Sign Language (BSL) from birth who has significant developmental deficits in the comprehension and production of BSL grammar based on formal assessment and linguistic analyses of his sign communication in comparison with age-matched unimpaired signers. It is shown that linguistic difficulties with BSL verb morphology underlie the child’s poor performance compared with same-age native signers. The appearance of linguistic impairments in sign and spoken languages in comparable domains supports cross-linguistic and modality free theories of specific language impairment. Cited examples of expressive language dysfluency in this article: child uses small sentences made up of one or two signs with very limited grammar, overuses sign repetition and pointing, and uses exaggerated facial expression and gestures.

Pollard, R. (1998). Psychopathology. In M. Marschark and M. D. Clark, Psychological perspectives on deafness, 2 (pp. 171-197).

In this book chapter, Pollard discusses special considerations in the clinical interview of deaf persons. Of most relevance is the section on language, communication, and translation. He discusses the variability in language skills in deaf people and the danger of misinterpreting communication dysfluency. He notes that while mental illness can affect language and thought patterns, most deaf persons who show dysfluency do so for reasons other than neuro- or psychopathology. He also describes how interpreters unprepared for the challenges of mental health interpreting and work with dysfluent persons can inadvertently contribute to clinicians making significant clinical misjudgments.

Pollard, R. Mental health and Deaf individuals: On-line training for clinicians. Missouri Department of Mental Health.

This online training provides an excellent overview of Deaf mental health issues. Unit 5 is devoted to language dysfluency, literacy, and fund-of-information issues. The goals of this unit are: 1) to understand the much greater range of language fluency found in deaf individuals, 2) to recognize the significance of language fluency deficits in relation to differential diagnosis in mental health service settings, 3) to be prepared to encounter and deal with language dysfluency in deaf patients, 4) to understand how interpreters may work in light of language dysfluency, 5) to understand why English literacy is compromised among many deaf persons, and 6) to learn about the meaning and significance of fund-of-information.

Thacker, A. (1994). Formal communication disorder: Sign language in deaf people with schizophrenia. British Journal of Psychiatry, 165, 818-823.

This study is a summary of research which demonstrated how formal communication disorders often found in persons diagnosed with schizophrenia can manifest in deaf persons with schizophrenia in their dysfluent sign communication. Sign language samples were elicited from 30 prelingually deaf adults diagnosed with schizophrenia, seven diagnosed with mania, and from a matched group of deaf controls. Preliminary analysis found multiple kinds of sign language errors. These include reversing the order of fingerspelling or movement of signs, producing signs in the wrong location, clanging (making association between signs based on formal properties like handshapes and not on meaning), switching or dropping topics abruptly, and repeating signs and themes unnecessarily.

Trumbetta, S. L., Bonvillian, J. D., Siedecki Jr., T., & Haskins, B. G. (2001). Language-related symptoms in persons with schizophrenia and how Deaf persons may manifest these symptoms. Sign Language Studies, 1(3), 228-253.

This article reviews core features of the disorganized speech seen in schizophrenia and illustrates how deaf persons with schizophrenia may display such language anomalies. It discusses the difficulties involved in studying language in persons with schizophrenia in general and specifically in deaf persons with schizophrenia. Some examples are given of sign language dysfluency related to thought disorder: decline in sign skills from previous level, stereotyped (repetitive) manner of signing, neologisms (invented signs unknown to other people), derailment (gradually losing focus), clanging by associating signs based on handshape and not meaning, incomplete references (which also occur in persons with language deprivation), prosody (intonation, stress, and rhythm), and facial affect not in agreement with sign communication. The authors also review the presence of other psychotic symptoms in deaf persons such as auditory, visual, and tactile hallucinations.