Community Ment Health J DOI 10.1007/s10597-017-0120-0 ORIGINAL PAPER 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 Charlene J. Crump1 · Stephen H. Hamerdinger1 Received: 24 May 2016 / Accepted: 6 February 2017 © Springer Science+Business Media New York 2017 Abstract Working with individuals who are deaf in which can create dysfluencies. Causalities for language mental health settings can be complex work, necessitat- dysfluency can include medical issues, mental illness, lan- ing consideration for the difference in language abilities. guage deprivation, and etiological causes of deafness. This These differences include not only the language differences paper primarily focuses on the influence of etiology in deaf of American Sign Language (ASL) and English, but also people who are mentally ill and the subsequent influence the range of heterogeneity within the Deaf Community. of effective and appropriate communication assessments on Multiple influences such as mental illness, medical condi- treatment. Much of this article draws upon the work of the tions, language deprivation and the etiology of deafness Alabama Department of Mental Health, which has state- can impact how a person acquires and uses language. This wide deaf-specific mental health services. article will discuss how various causes of deafness create Few states provide statewide mental health services the potential for specific language dysfluencies with indi- appropriate for deaf or hard of hearing individuals (Gour- viduals who are deaf in mental health settings. The article naris et al. 2013). Those that do are often challenged with will also discuss the use of communication assessments to budget and staff shortages, as well as the continual struggle examine specific language dysfluency patterns and attempt to advocate the need for specialized services in a hearing- to offer possible corresponding interventions. centric environment. Those programs that do provide deaf- specific programming must also deal with the challenges Keywords Deaf · Mental health · Dysfluency · Etiology · of service provision across large geographical areas and Language deprivation · Communication assessment clients who have complex and uniquely challenging needs. These clients, often referred to as difficult to serve, are labelled with such terms as Low Functioning Deaf (Bowe Introduction 1998), Minimal Language Skills (Leigh 1999), Tradition- ally Underserved and Language and Learning Challenged Mental illness can have significant impact on an individ- (Glickman 2009). ual’s quality of life. Diagnosis and treatment can be com- The smaller, localized programs are not spared these plex when the individual with a severe and persistent men- shortfalls. In a chaotic environment that demands constant tal illness is also deaf, and does not share the same cultural vigilance to ensure financial survival, local programs must and linguistic foundation as the provider, nor the system. take care that they generate enough “billable” hours that In addition to cultural and linguistic differences, a person can meet payroll and keep the business viable. Despite legal who is deaf may experience various language influences requirements for accessible services (ADA Title III 1990), programs rarely have time to think systemically about the various peripheral issues related to service provision, such * Charlene J. Crump as how dysfluency, its origins and lack of intervention, con- [email protected] found service effectiveness. 1 Alabama Department of Mental Health, P.O. Box 301410, Both deafness and mental illness can impact language Montgomery, AL 36130, USA use and/or acquisition. Certain mental illnesses that cause Vol.:(0123456789)1 3 Community Ment Health J thought disorders also impact language abilities (Diag- In social settings, questions regarding how an individ- nostic and Statistical Manual of Mental Disorders 2013). ual became deaf are perceived as focusing on a medical or Inadequate competency of language affects all areas of pathological viewpoint, and are not considered culturally life including learning, social relationships, education, appropriate questions. Pursuing that particular line of ques- employment, rehabilitation and mental health treatment. tioning is often discouraged and may be perceived as being Dr. Robert Q. Pollard notes that “Psychiatry is unique insensitive (Holcomb and Mindess 2008). In a clinical set- among the medical fields in that most of the symptoms ting, though, “Deaf, How?” can have critical impact on the are conveyed by or through communication, and commu- care and treatment of clients. nication also is the primary method and nature of treat- People who are hearing are usually born into environ- ment” (Pollard and Dean 2003). Because clinicians use ments where they are exposed to and learn language. Thus, language and behavioral analysis as diagnostic criteria, severe language dysfluency in hearing people often occurs those who work with deaf people but do not sign flu- or is assumed to occur as a result of cognitive impair- ently, nor have a thorough understanding of deafness and ment, traumatic brain injury, or psychosis (Robinson the parameters of normalcy, can misconstrue the causes 1991; Crump and Glickman 2011). Language deprivation and implications of language dysfluency. Subsequently, among hearing people is a rare phenomenon (Gulati 2014). this lack of understanding can lead to misdiagnoses of Among congenitally deaf people, however, language dep- psychosis or severe developmental disability, worsen rivation is a more common experience. A small fraction behavioral problems and complicate services to the deaf of congenitally, or hereditarily, deaf people are born into population. families that use some form of visually accessible com- This paper does not suggest that deafness equates to an munication (Karchmer and Mitchell 2004). Another frac- inability to acquire and use language fluently. In and of tion is left essentially with no exposure at all to language itself, lack of hearing does not create a barrier to the poten- (Schaller 1991). The vast majority of people who are deaf tial to acquire language. Confusion often occurs when unin- fall between those extremes (Pollard 2003). formed people conflate the ability to speak English—or any Being able to tease out where dysfluency is related to other language, for that matter—with cognitive functioning lack of language exposure, and where it might relate to in general. neurological sequelae of genetic disease or trauma that Lack of exposure to visual language throughout a deaf also resulted in deafness, is incredibly challenging, even individual’s lifetime—specifically signed languages—is for those who have more experience in, and are more quali- mentioned by others as an element of the observed phe- fied in, looking for and differentiating these causes (Black nomena of dysfluency (Mayberry 2002; Crump and Glick- and Glickman 2005). Glickman (2007, 2009) writes about man 2011). Inadequate language can exist due to many rea- patterns of language related to deprivation. These com- sons, including mental illness (Pollard 1998; Thacker 1994, mon errors include impoverished vocabulary, inability 1998; Trumbetta et al. 2001), medical causes (Klima and to sequence events in time, lack of indicators related to Bellugi 1979; Poizner et al. 1987), lack of language expo- tense, inadequate story structure, spatial disorganization, sure/models (Glickman 2007, 2009; Vernon and Andrews unclear references, incorrect syntax, sign repetition, and 1990), etc. However, the literature pays scant and superfi- an increased use of gesture to substitute for poor word cial attention to the etiological cause of deafness in regards development. to how those specific language patterns of dysfluencies, In most non-deaf-specific mental health systems, clini- their impact on the assessments and treatment of mental ill- cians do not sign fluently, if at all. They are not trained to ness, and even less to modifying treatment approaches. work specifically with deaf people and rarely have a regu- Regardless, or perhaps because of the pervasiveness of lar and substantial caseload of deaf people. The idea that language deprivation, it is critical to consider that in some severe dysfluency might have a cause other than cogni- individuals, the neurological consequences that coexist tive disability or psychosis is rarely found in their schema. with the etiology of deafness can have potential impact on This is one of the reasons deaf people with mental illness language acquisition and use (Some Causes of Childhood can carry so many varied and often contradictory diagno- Permanent Hearing Loss 2006). Some causes of deafness ses (McEntee 1993). A clinician who does not share the may also create other neurological, medical or psycho- same language as the client will have a difficult time dif- logical problems, any of which can impact language, apart ferentiating linguistic patterns associated with language from acquisition (Soren and Druzin 2003), which can be deprivation from those associated with cognitive issues or very important to a mental health clinician. How a person mental illness. They will assume that the introduction of an became deaf is an important piece of information that helps interpreter resolves those deficits (Hamerdinger and Karlin clinicians understand the clinical presentation of mental ill-