We will all see patients who are either non-verbal or who have limited speech and, while this may bring to mind people such as Jean-Dominique Bauby who wrote ‘The diving Bell and the Butterfly’ while suffering from locked-in syndrome, not all patients will be as challenging.1

Patients may be non-verbal for a number of reasons but there are two main causes:

  • Speech impairments – physical problems of making the correct speech sounds.
  • Language problems – cognitive problems concerning the use of language.

While the thought of conducting an eye examination or dispensing with a non-verbal patient may be daunting, most of us will possess the skills we need for a successful outcome.  Unfortunately, non-verbal patients are also likely to be poor self-advocates, having difficulty telling people that there is a problem with their vision. This makes it even more important that we provide a thorough, comprehensive and regular examination.

Of the patients we see in practice who are non-verbal, there will be those that have lost the verbal skills they once had such as in the case of patients who have had a stroke. Others are pre-verbal and have not yet developed verbal skills, such as very young children. There are also patients who have never developed verbal skills, such as those with learning difficulties or, more rarely, the patient who is an elective mute.

It is also worth considering those patients with whom we do not share a first language and those who are profoundly deaf and only have limited verbal communication or may have difficulty making recognisable speech, as we may encounter similar problems when seeing them.

Causes of non-verbal behaviour – the silent adult

Aphasia

Aphasia causes disruption to speech due to damage to the brain. It can be caused by stroke, traumatic head injury, dementia or brain tumour.2 Aphasia is a problem with language rather than a problem with speech and it can affect the written word as well as the spoken word. Aphasia may affect how an individual is able to express themselves or their understanding of others.3 It may present in different forms.

Expressive Aphasia

This is an inability to get your thoughts and ideas across. It may lead to slow or halting speech and problems with remembering names for people and places. It can lead to a very staccato speech pattern using basic elements such as ‘want glasses’ or even misnaming things such as saying chair instead of table.

Receptive Aphasia

Receptive aphasia is an inability to understand what other people have said or to interpret written information and can give rise to inappropriate responses to questions. This may lead to problems during a history and symptoms and failure to offer the response to the questions we ask. We may receive false information that is not obviously wrong, such as to questions about medication or the presence or absence of symptoms.

These categories are not exclusive and may indeed overlap. In dementia the effects are progressive leading to worsening understanding and problems with the ability to speak.  

A few simple changes can help us to communicate with someone who has aphasia more effectively:

  • Use short sentences and closed questions with simple ‘yes/no’ answers.
  • Allow plenty of time to process the question.
  • Allow time for a reply rather than immediately rephrasing the question.
  • Encourage the patient to use gestures, such as thumbs up or pointing.
  • Listen to the intonation as the tone of voice may indicate more than the words used.
  • Avoid confusion by using names rather than ‘he’ or ‘she’ and perhaps use photographs to identify the person.
  • Avoid sudden changes of subject and indicate that you are going to talk about something else, for instance saying ‘I am going to ask about your health now’ during history and symptoms.4
  • Finishing off sentences for someone or correcting them when they use the wrong word can lead to resentment and frustration, as can pretending that you can understand them when you do not.

Tracheostomy

A tracheostomy is an opening in the front of the neck.5 A short tube is then inserted to allow breathing. There is an outer tube which remains in place, an inner tube that is removable for cleaning and a cuff on the neck. The cuff can be attached to an oxygen supply or ventilator if necessary. They are used in patients where there is a blockage in the throat and they are unable to breathe normally. This may be due to tumour or swelling or they may be used if the person is unable to breathe normally, such as following injury or due to muscle weakness such as in motor neurone disease. The tube allows the passage of oxygen but because air no longer passes across the vocal cords the individual is unable to produce sounds normally. In some cases, the tracheostomy tube will have a speaking valve attached which allows a temporary closure to facilitate speech.

It is normal for people with a tracheostomy to be seen by speech and language therapists (SLTs).5 SLTs work with patients to improve swallowing and many patients with a tracheostomy manage to eat and drink normally after a short while. SLTs will also work on alternative communication techniques to relieve the frustration of not being able to communicate.

Causes of non-verbal behaviour – the silent child

The topic of communicating with children is beyond the scope of this article, but we will however consider the special case of the selectively mute child.

Selective mutism (SM) is a rare condition where a child is unable to speak in a social situation. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists it as an anxiety disorder where a child consistently fails to speak in a specific social situation such as school.6 A diagnosis of selective mutism requires the absence of speech for a month but many of us will recognise small children who display similar symptoms during an appointment. In fact, it is a normal part of development for children to be reticent about speaking.

Children with SM can often make themselves understood using gestures such as nodding or shaking their head. They may even manage the odd word but that will often be whispered. They tend to be nervous and socially awkward. They can be very clingy and may even be stubborn and aggressive.7

Treatment is not focused on speech as these children are not unable to speak but takes a behavioural approach to overcome the anxiety.8,9 During an appointment we can help by reassuring the child as follows:10

  • Explain to them that you understand how difficult it can be to talk to a stranger.
  • Do not exclude the child, carry on talking to them even if you do not receive an answer.
  • Do not overreact if they do start to talk. Respond to what they have said rather than to the fact that they have said it.
  • Do not try to bribe them to talk.
  • Do not pressure the child to make eye contact.
  • Allow the child to communicate in other ways. For instance give them choices that they can point to and be aware of other gestures.

Causes of non-verbal behaviour – learning difficulties

Not all patients who have a learning disability will be non-verbal, and even those that are may well understand spoken language. The main causes of being non-verbal when associated with a learning disability include:

  • Physical problems making spoken words such as those encountered in cerebral palsy.
  • Cognitive problems relating to the understanding and production of speech.
  • Manifestation of an underlying condition itself, such as the silent patient who has an autistic spectrum disorder.

Causes of non-verbal behaviour – other causes

Deafness

It has been shown that deafness can lead to isolation and poor access to services such as health.11 Deafness can be either congenital or acquired. Acquired deafness usually occurs later in life and generally leads to an impairment in hearing rather than profound deafness. Congenital deafness is normally more profound and has a significant impact. Not all patients with hearing loss will use hearing aids or use sign language and some patients may not acknowledge their problem.

Those with acquired hearing loss, often referred to as (lowercase) deaf, tend to view deafness as a problem or loss to be overcome. Whereas (uppercase) Deaf people have a definite cultural identity as Deaf with a shared language and values.12

Those patients who are Deaf will have a strategy for coping in a hearing world whereas those who are deaf are likely to be more of a challenge for practitioners. Avoid shouting and exaggerated facial expressions. Speak clearly and use short sentences. Check regularly for understanding and use supporting written information where appropriate.11

The eye examination

The eye examination can be considered to have three phases:

  • The history and symptoms.
  • The examination.
  • The patient discussion.

Non-verbalism can impact on all of these. Obviously for testing there are a number of objective tests we can use such as retinoscopy to establish a prescription but even these will need some explanation of the process. The other two areas are more complex, relying on interaction to be successful.

Many non-verbal patients will attend for an appointment with a communication partner. This may be a translator for someone who does not speak the same (verbal) language as we do, or a sign language interpreter. In other cases, they may just be more attuned to the verbalisations an individual is able to make and, while this can be of huge benefit, we need to remember to address our questions and comments to the patient. First of all this is good manners but it also allows us to read the body language. We are not able to control what an interpreter actually says to the patient or reports to us but observing the body language will provide valuable information.

This also highlights the importance of observation. With a truly non-verbal patient observation is a key skill. How do they investigate the unfamiliar surroundings of the consulting room? How well do they navigate their way in? These observations provide clues as to how someone is seeing and what their needs may be.

Dispensing

Dispensing provides different challenges especially when it comes to describing lens choices such as varifocals. Various communication tools are available. These are often referred to as augmentative and alternative communication or AAC. AAC is a way of complementing the spoken word to help those who have trouble communicating. It can be:

  • No-tech.
  • Low-tech.
  • High-tech.

No-tech AAC requires no extra equipment and can be as simple as gestures, facial expressions or pointing, thumbs up, thumbs down, or establishing a shared understanding of what the limited vocalisations someone can make means. This understanding is often established with input from the person who accompanies the patient and it is worth developing as it lessens the frustration for both parties of asking the carer.

Low-tech AAC does not need batteries. It is often just writing things down or can be more complex such as the use of communication books with pictures or symbols. An example of this is the letter matching chart from the Sheridan Gardiner test or the picture matching chart from the Kay acuity test.

No-tech AAC also encompasses sign language. The British finger spelling alphabet is relatively easy to learn and being familiar with the letters used on your chart means that you can accurately record VAs. Simple sign language for ‘Hello’ and ‘My name is…’ is also useful. Resources can easily be found on the web or there are many local classes available.

Other patients may have a communication passport. This is a document that contains easily accessible information about the person. It will include how they communicate as well as what they like to be called, what their likes and dislikes are and relevant clinical information. You may be asked as a health care professional to contribute your findings to a communication passport. It is important to remember that, although you are providing clinical information, you are not writing a medical report and it should be understood by non-medical people. An example might be, rather than saying that someone is short-sighted, you might include ‘I need to wear my glasses to watch the TV.’

High-tech AAC is more complex and generally involves speech synthesis. The devices range from a very simple push button that can repeat a simple pre-recorded phrase such as ‘Hello, my name is Peter’ to more complex systems that can synthesise normal speech using eye pointing, such as that used by Professor Stephen Hawking.

High-tech AAC is becoming much more common with the availability of mobile technology such as the smart phone or tablet, and we are all more likely to come across patients who use it. This sort of technology does provide a challenge for optometrists and dispensing opticians as we need to ensure that our patients can see the device well enough to use it.

Challenge

Successfully helping non-verbal patients can be a challenge and, due to improvements in health care and longer life expectancy as well as changes in social policy to include people with disabilities in everyday life, means we are likely to see an increasing number of non-verbal patients in practice. Fortunately an understanding of some of the causes of non-verbalism and the use of some simple techniques can improve outcomes for both practitioner and patient. 

Andy Millington is an optometrist with a private practice in Chepstow and teaches at Cardiff University where he has been instrumental in the development of the special clinic service aimed at children with learning and cognitive impairment.

References

1 Kirkup J. Obituary: Jean-Dominique Bauby. The Independent 1997. Available from: http://www.independent.co.uk/news/people/obituary-jean-dominique-bauby-1272406.html.

2 NHS. Aphasia.

3 stroke.org.uk. Communication problems after stroke 2012.

4 Stokes G, Goudie F. The essential dementia care handbook : a good practice guide. Bicester: Speechmark; 2002.

5 NHS. Tracheostomy 2015.

6 Muris P, Ollendick TH. Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5. Clin Child Fam Psychol Rev. 2015;18(2):151-69.

7 NHS. Selective Mutism 2014.

8 Melfsen S, Warnke A. [Treatment of selective mutism]. Z Kinder Jugendpsychiatr Psychother. 2007;35(6):399-407; quiz 8-9.

9 Kumpulainen K. Phenomenology and treatment of selective mutism. CNS Drugs. 2002;16(3):175-80.

10 In_Train. Talk About: A guide to selective mutism2015.

11 RNID. RNID Fact Sheets  [30.11.2016]. Available from: www.actiononhearingloss.org.uk/supporting-you/factsheets-and-leaflets.aspx.

12 Napier J. The d/Deaf h/Hearing Debate. Sign Language Studies 2002.