clinical junior.com - Communication and Intellectual Disability Psychiatric patients mental

The following document was written by Dr Swapnil Palod, ST5 in Psychiatry of Learning Disabilities (St. George’s Higher Training Scheme, London) and Dr Meetiksha Malhotra, ST5 in Child and Adolescent Psychiatry (St Mary’s Higher Training Scheme, London) September 2010
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Introduction

“To effectively communicate, we must realize that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others”.
- Anthony Robbins

Communication is important in all the aspects of life. It has a crucial role in the field of medicine. It would be difficult to diagnose and treat patients if we are unable to communicate with them. Good communication skills amongst doctors may lead to identification of problems more accurately, greater satisfaction amongst patients and less work stress amongst doctors.

Various methods of communication:

Verbal
Non verbal
- Written
- Visual
Other approaches:
- The Picture Exchange Communication System (PECS)2
- Makaton
- British Sign Language

Why communicate with people with intellectual disabilities?

Some clinicians may think “Why should I talk to him/ her (person with ID) and waste time? It will take forever.” But if they think carefully, they’ll realise that how important it is to communicate with the individual with ID using various creative methods and also listen to people’s families and carers. This may take more time than usual, but it is ‘better to get it right rather than to get it fast’. Who else would be able to inform you about their problem other than the patients themselves?

People with ID have higher prevalence of various medical conditions including epilepsy, hypothyroidism, dementia, poor dental hygiene, sensory problems, etc5. Hence it is essential to have appropriate skills to communicate effectively with them in order to effectively diagnose and treat these conditions.

The General Medical Council in the guidance Good Medical Practice states that the clinicians should share the information in a way that the patients can understand. The guidance also adds that “You must make sure, wherever practical, that arrangements are made to meet patients' language and communication needs”.

Effective communication can be helpful to develop:

Improved understanding and management of physical and mental health conditions as clinicians are able to build up better rapport. This is possible as there is proper recognition of developmental age, hence being able to do the assessment at appropriate level.

Provision of holistic package of care wherein the social, educational, financial needs of patients can be addressed.

Prevention of further cases where indifference towards people with ID and problems in communication led to extreme and fatal consequences.

How to communicate with people with ID?

“True sign of intelligence is not knowledge but imagination”.
- Albert Einstein

It is essential to involve the person with ID at every stage of consultation as much as possible. However, it may be a challenging task to communicate with them. This may be due to several factors including unfamiliarity, anxiety, stigma, etc. Hence, we need to be creative in dealing with people with ID. This article aims to provide tips and creative ways to communicate with people with ID.

Mahrabian and Ferris found that words (verbal) account for only 7% of communication, the voice tone (vocal) accounts for 38% and general body language (visual) accounts for 55% of the communication, thus showing that the body language has a great impact in terms of communicating with others.

The following tips are only guidelines rather than strict rules. Some of them may work but some may not. So the important thing is to be creative and grab opportunities as they arise. These approaches may take a longer time but are useful to identify the person’s needs and addressing them in a better manner.

It is very important to speak to the carers who know the person well, to get to know the likes and dislikes of the person with ID. However talking to the carers at great length may not be possible in some emergency settings for example in A&E. But most likely the person with ID would attend the A&E accompanied by a carer. This is true especially with more severe forms of ID. Hence the clinicians should grab this opportunity and spend whatever time is available with carers.
Introduce yourself and explain why you are talking to them.
Setting/ Environment: Communicate with the people with ID at a place where they are most comfortable for example the day centre, residential home, etc.

Even minor things like what you wear can sometimes make a difference. There was a person with ID who did not like blue jumpers and I remember wearing the colour on a visit to see him. He was upset on seeing me and repeatedly said “Don’t like you. Blue.” I did not understand but the carer helped me solve the puzzle. The easy solution then was to remove the jumper and talk to the patient. That’s what I did!

In the document Treat me Right!, it is mentioned that many people with ID and their carers suggested that longer and more accessible appointments with health professionals would help them a great deal as they would feel less rushed and more able to express themselves.
Content/ Language:
- Start the conversation by talking about something they like to talk about and thus making them comfortable.
- Ask short and simple questions and avoid jargon - use simple language and familiar words.
It is crucial to use appropriate facial expressions as there is a lot of evidence highlighting the importance of non-verbal communication.
It is important to set the pace of the session at a comfortable level for patient, giving them enough time to answer and express themselves.
Sometimes a person can have better writing skills than verbal skills. So give them a pen and paper.
Communicating by drawing or showing different pictures- PECS2 and using signs & symbols - Makaton.
Aids like communication passports, hospital passports can be useful to know the background about the person with ID.

Books Beyond Words

The series of Books Beyond Words9 is a very useful resource in helping people with learning and communication difficulties, edited by Prof Sheila Hollins. These titles can be used with people who understand pictures better than words. The books deal with some difficult issues and events in a simple and understandable way using pictures. The titles include ‘Going to the doctor’, ‘Getting on with Epilepsy’ and ‘When Mum Died’.
http://www.rcpsych.ac.uk/publications/booksbeyondwords/aboutbbw.aspx

Speech and Language Therapists

Speech and Language Therapists play a crucial role to play in assessing and treating speech, language and communication problems in people with ID. This helps them to reach their full potential in terms of communication. The therapists also work with people having eating and swallowing problems.

References:

Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325:697-700.
Bondi AS, Frost LA. The Picture Exchange Communication System. Focus on Autism and Other Developmental Disabilities 1994; 9(3):1-19.
Walker M, Armfield A. What is Makaton vocabulary? Spec Educ Forward Trends 1981; 8(3):19-20.
Mencap. Treat me right! Better healthcare for people with a learning disability. Mencap, 2004.
Fraser W, Kerr M. Seminars in the Psychiatry of Learning Disabilities. Royal College of Psychiatrists. 2nd Edition, 2003.
General Medical Council. Good Medical Practice. GMC, 2006.
Mencap. Death by Indifference: Following up the Treat me right! report. Mencap, 2007.
Mehrabian A and Ferris SR. Inference of Attitudes from Nonverbal Communication in Two Channels. Journal of Consulting Psychology 1967; 31(3):248-25.
Hollins S et al. Books beyond Words. Royal College of Psychiatrists.

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