In the past, a person with deafness was often diagnosed with an intellectual disability or psychiatric disorder, said Karen Goldberg, M.D., at the annual meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) last October in Chicago.

Research over the last 40 years has increased understanding about mental health issues among deaf people, but communications barriers still frequently lead to misunderstandings between them and health care professionals or to misinterpretation of behavior that may or may not be psychopathological.

Goldberg is assistant medical director at the National Deaf Academy (NDA), a private residential center in Mount Dora, Fla., that treats deaf patients with severe psychopathology, and knows firsthand about hearing loss. She discovered her own hearing difficulties when she was shifted to the back of the classroom as a 7-year-old.

"All of a sudden, I became very stupid," she said, recalling the consequences of her disconnection from the teacher's voice. She learned to compensate by sitting in the front of her classes, and she also learned about the stigma attached to deafness when her parents told her to keep it secret.

Many hearing parents of deaf children see hearing loss as pathology to be treated and overcome. They want their children to hear and speak like" normal" people. They opt for "oralism": reading lips and learning to speak aloud, and often adopt technological solutions to deafness, like cochlear implants.

In contrast, many deaf people see themselves as members of a cultural and linguistic minority built around American Sign Language. Goldberg and other speakers at the AACAP workshop are firmly in this second camp. To them, not learning sign language while waiting until children are old enough to receive implants creates another developmental obstacle.FIG1

"During the time that the parents are pursuing implantation they rarely also use sign language, and many cochlear implant programs discourage it," said Sanjay Gulati, M.D., a child psychiatrist at Cambridge Hospital and an instructor in psychiatry at Harvard. Gulati lost most of his hearing between the ages of 10 and 30, and now specializes in care of children who are deaf.

"So on top of any language delay the child might already have, the [implantation and associated] rehabilitation period can add additional language delay," he said.

"Communication difficulties between parents and deaf children impair attachment, bonding, and the child's psychological development," said Goldberg. The parents' reaction to a diagnosis of deafness may also increase the child's sense of isolation or rejection.

"If children can't communicate in language, they may resort to acting out and end up with a diagnosis of oppositional defiant disorder or conduct disorder," said Gulati.

The staff at the NDA often has to teach incoming students signs, social skills, and reciprocal conversation skills before they can start treatment. IQ tests, unless given by a fluent signer, may not convey an accurate picture of a deaf person's cognitive skills.

Working with deaf patients who also have psychiatric disorders is difficult and demands an insight into the world of the deaf, said Gulati.

Deafness may arise from any of several causes.

"Traumatically or organically acquired deafness [from, say, rubella infection, neonatal oxygen treatment, or meningitis] is often accompanied by learning disability or other cognitive deficits that can lead to or predispose to behavior problems," said Gulati in a later interview.

"Because some syndromic deafness [hearing loss linked to a medical illness] is associated with cardiac or renal problems, I routinely screen for these conditions as part of initial workup or before starting a medication," he said.

Typical screening includes blood urea nitrogen, creatinine, renal ultrasound, and an EKG. Key considerations include the use of stimulant medications for attention-deficit/hyperactivity disorder, which requires EKG screening; and the use of lithium for bipolar disorder, major depressive disorder, or intermittent explosive disorder. Patients taking lithium must be followed for kidney function.

"Side effects of psychotropic medication are a common problem, too, since it is often more difficult [with deaf patients] to establish the level of trusting rapport needed to help a patient deal with difficult side effects," he said. "Many patients will simply stop a medication and not return to the doctor—and then sometimes mistakenly conclude that no medicine will work for them."

Often doctors misunderstand how the experience of deafness alters psychiatric presentation, resulting in misdiagnosis, he said.

There are other difficulties as well in dealing with deaf patients with psychiatric problems. For example, said NDA counselor Melissa Watson, M.A., at the AACAP meeting, "Deaf people tend to be blunt." They may also throw in extra words, a sign of possible agitation but not of schizophrenia. Sometimes they go into excessive detail, which can be confused with obsessive-compulsive symptoms. They may report "hearing voices," but since most deaf people are not totally deaf, they may hear some real sounds that they try to explain as voices.

"A clinician may assume a deaf child has an attentional problem when the real problem is that communication in the classroom is not working for the child or that his or her academic ability has been overestimated in some ways or underestimated in others by testers unfamiliar with deaf children," said Gulati.

Psychiatrists and mental health professionals should work with an expert sign language interpreter, one with knowledge of the subject matter as well as the signing skills, to avoid confusion. Gulati frequently uses a certified deaf interpreter for patients who are not fluent in American Sign Language and for those who are psychotic, brain damaged, or significantly language deprived.

"Interpreters must be experienced in mental health or they will get confused and think they are missing something or misunderstanding the patient or the doctor," said Watson. Interpreters do their utmost to serve only as a conduit or facilitator, without injecting their own thoughts into the conversation, she said. Using them has other advantages, too.

"It's cheaper to pay for an interpreter than to pay malpractice claims," she said. ▪