The article below was published in the July/August 1997 edition of Disability Solutions. It is republished with permission. A PDF copy of the article can be downloaded at this link.
Do you talk to yourself? We all do at different times and in various situations. In examining and evaluating over 500 patients at the Adult Down Syndrome Center of Lutheran General Hospital, we have heard repeatedly that adults with Down syndrome talk to themselves. Sometimes, the reports from parents and caregivers reflect deep concern that this behavior is "not normal" and symptomatic of severe psychological problems.
Preventing misinterpretation of self-talk as a sign of psychosis in adults with Down syndrome is a major motivation for this article. Too often, we believe, these conversations with self or imaginary companions have been equated with "hearing of voices" and treated with anti-psychotic medications (such as Haldol®, Mellaril®, or Risperdal®). Since it is extremely difficult to evaluate the thought processes of adults with cognitive impairments and limited verbal skills, we urge a very cautious approach in interpreting and treating what seems to be a common and at times very helpful coping behavior for adults with Down syndrome.
The Adult Down Syndrome Center (the Center) was developed to address the health and psycho-social needs of adults with Down syndrome.1 The Center is a unique collaboration of the National Association for Down Syndrome, a parent advocacy group, Advocate Health Care, a private healthcare provider, and the Institute on Disability and Human Development at the University of Illinois at Chicago. Since its inception in 1992, over 500 individuals have been evaluated at the Center.
Our records at the Center indicate that 81 percent of the adults seen engage in conversations with themselves or imaginary companions. Patients have ranged in age from 11 to 83 years of age. The median age in our data base is 34. This high prevalence of self-talk does not seem to be widely known. For some parents and caregivers, the fact that "almost everyone with Down syndrome does it" is reassuring. But the content of these conversations, their frequency, tone, and context can be important in determining if treatment is warranted.
Families and caregivers should understand that self-talk is not only "normal" but also useful. Self-talk plays an essential role in the cognitive development of all children.2 Self-talk helps children coordinate their actions and thoughts and seems to be an important tool for learning new skills and higher level thinking.3 Three-year-old Suzy says to herself: "This red piece goes in the round hole." Then Suzy puts the red piece into the round hole of the puzzle.
We suspect that self-talk serves the same useful purpose of directing behavior for adults with Down syndrome. Consider the case of twenty-two-year-old "Sam" (not his real name). His mother reported the following scene. She asks Sam to attend a family function on a Sunday afternoon. Sam's regular routine is to go to the movies on Sunday afternoons. Sam tells his mother he will not go with the family. Then the mother asks Sam to think it over. Sam storms off to his room and slams the door.
His mother overhears this dialogue:
"You should go with your family, Sam."
"But I want to go to the movies."
"Listen to your Mom!"
"But Sunday is my movie day."
"You can go next Sunday."
Sam's mother said he went to the family function, with the proviso that he could go to the movies the next Sunday. Sam may have been talking to an imaginary person or arguing with himself, but Sam clearly managed to cope with a situation not to his liking.
In children without identified learning problems, the use of self-talk is progressively internalized with age. Moreover, children with higher intellectual abilities seem to internalize their self-talk earlier. As self-talk is transformed into higher level thinking, it becomes abbreviated and the child begins to think rather than say the directions for his or her behavior. Thus, the intellectual and speech difficulties of adults with Down syndrome may contribute to the high prevalence of audible self-talk reported to us at the Center.
In general, the functions of self-talk among adults are not as well researched or understood. Common experience suggests that adults that continue to talk to themselves out loud when they are alone and confronting new or difficult tasks. Though the occurrence may be much less frequent, the uses of the adult's self-talk seem consistent with the findings about children. Adults talk to themselves to direct their behavior and learn new skills. Because adults are more sensitive to social context and may not want others to overhear these private conversations with themselves, their self-talk is observed less frequently.
Adults with Down syndrome show some sensitivity about the private nature of their self-talk. Like Sam in the example above, parents and caregivers report that self-talk often occurs behind closed doors or in settings where the adults think that they are alone. Having trouble judging what is supposed to be private and what is considered "socially appropriate" also may contribute to the high prevalence of easily observable self-talk among the patients visiting the Center.
In the general population, self-talk among older persons is frequently notable and, usually, easily accepted, just as it is with children. Among the elderly, social isolation and the increasing difficulty of most tasks of daily living may be important explanations for this greater frequency of self-talk. For adults with Down syndrome, these explanations also make sense. Adults with Down syndrome are at greater risk for social isolation and the challenges of daily living can be daunting.
Additionally, we have found that many adults with Down syndrome rely on self-talk to vent feelings such as sadness or frustration. They think out loud in order to process daily life events. This is because their speech or cognitive impairments inhibit communication. In fact, caregivers frequently note that the amount and intensity of self-talk reflects the number and emotional intensity of the daily life events experienced by the individuals with Down syndrome.
For children, the elderly, and adults with Down syndrome, self-talk may be the only entertainment available when they are alone for long periods of time. For example, a mother reported that her daughter "Mary" spent hours in her room talking to her "fantasy friends" after they moved to a new neighborhood. Once Mary became more involved in social and work activities in her new neighborhood, she did not have the time or the need to talk to her imaginary friends as often.
Thus, that adults with Down syndrome use self-talk to cope, to vent, and to entertain themselves should not be viewed as a medical problem or mental illness. Indeed, self-talk may be one of the few tools available to adults with Down syndrome for asserting control over their lives and improving their sense of well-being.
When to Worry
The distinction between helpful and worrisome self-talk is not easy to cast in stone. In some cases, even very loud and threatening self-talk can be harmless. This use for self-talk by the adult with Down syndrome may not be that different from someone who rarely swears but screams out a four-letter word when hitting her thumb with a hammer. Such outbursts may simply be an immediate, almost reflexive outlet for some of life's frustrations.
Our best advice about when to worry is to listen carefully for changes in the frequency and context of the self-talk. When self-talk becomes dominated by remarks of self-disparagement and self-devaluation, intervention may be warranted. For example, it may be quite harmless when "Jenny" yells "I am a dummy," once, right after her failure to bake a cake from scratch. However, if Jenny begins to tell herself over and over "I am a dummy and can't do anything right," it may be time to worry and to do something.
A marked increase in the frequency and a change in tone of the self-talk also may signal a developing problem. For example, a caregiver reported that "Bob" had begun to talk to himself more frequently and not just in his room at the group home. Bob seemed to lose interest in his housemates and spent more time in these conversations with himself. Bob talked to himself, sometimes loudly in a threatening manner, at the bus stop, at the workshop, and at the group home. Bob was diagnosed as experiencing a severe form of depression. Over an extended period of time, Bob began to respond to an anti-depressant and to his participation in a counseling group.4
In another case, "Jim" (like Bob) showed a dramatic increase in self-talk. Jim refused to go to his workshop and to participate in the social activities that he once enjoyed. It turned out that Jim's change in behavior was not due to depression. Instead, Jim's family and staff at his workshop discovered that Jim was being intimidated and harassed by a new co-worker. With the removal of the bully from his workshop, Jim gradually regained his sense of trust in the safety of the workshop. His self-talk and interest in participating in activities returned to earlier levels.
Further study of the content, context, tone, and frequency of the self-talk of adults with Down syndrome may provide more insight into their private inner worlds. What we have observed and heard from family and caregivers suggests that self-talk is an important coping tool and only rarely should it be considered a symptom of severe mental illness or psychosis. A dramatic change in self-talk may indicate a mental health or situational problem. Despite the odd or disturbing nature of the self-talk, our experience at the Center indicates that self-talk allows adults with Down syndrome to problem-solve, to vent their feelings, to entertain themselves, and to process the events of their daily lives.
Dennis McGuire, PhD is Coordinator of Psychosocial Services for the Adult Down Syndrome Project of the Institute on Disability & Human Development at the University of Illinois at Chicago.
Brian Chicoine, MD is Medical Director of the Adult Down Syndrome Center of Lutheran General Hospital.
Elaine Greenbaum, PhD was Research Coordinator at the Adult Down Syndrome Center of Lutheran General Hospital
1. Chicoine, B., McGuire, D., Hebein, S., and Gilly, D., "Development of a Clinic for Adults with Down Syndrome." Mental Retardation, Vol. 32, No. 2, 1994, p.100-106.
2. Private speech is the term used for self-talk in literature on child development. For a wide range of references on the use of private speech: Diaz, R., Berk, L. Private Speech: From Social Interaction to Self-Regulation. Lawrence Erlbaum Associates, 1991. ISBN: 0805808868
3. L.S. Vygotsky is the Russian psychologist credited with explaining how higher thought and our inner silent dialogues emerge from childhood's private speech: Vygotsky, L., in Diaz, R., Berk, L. Private Speech: From Social Interaction to Self-Regulation. Lawrence Erlbaum Associates, 1991. ISBN: 0805808868
4. McGuire, D., Chicoine, B., "Depressive Disorders in Adults with Down Syndrome." The Habilitative Mental Healthcare Newsletter, Vol. 15, No. 1, 1996, p.1-7.