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July/August, 1997 - Volume 2, Issue 2
"Self-Talk" in Adults with Down Syndrome
by Dennis McGuire, Ph.D., Brian A. Chicoine, MD.,and Elaine Greenbaum, Ph.D. Do you talk to yourself? We all do at different times and in various situations. Inexamining and evaluating over 500 patients at the Adult Down Syndrome Center ofLutheran General Hospital, we have heard repeatedly that adults with Down syndrometalk to themselves. Sometimes, the reports from parents and caregivers reflect deepconcern that this behavior is "not normal" and symptomatic of severe psychologicalproblems.
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, theseconversations with self or imaginary companions have been equated with "hearing ofvoices" and treated with anti-psychotic medications (such as Haldol, Mellaril, orRisperdal). Since it is extremely difficult to evaluate the thought processes of adults withcognitive impairments and limited verbal skills, we urge a very cautious approach ininterpreting and treating what seems to be a common and at times very helpful copingbehavior 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. The Center is a uniquecollaboration of the National Association for Down Syndrome, a parent advocacy group,Advocate Health Care, a private health care provider, and the Institute on Disability andHuman 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 adults seen engage in conversations with themselves or imaginary companions. Patients have ranged in agefrom 11 to 83 years of age. The median age in our data base is 34. This high prevalenceof self-talk does not seem to be widely known. For some parents and caregivers, the factis reassuring. But the content of these conversations, their frequency, tone, and contextcan be important in determining if treatment is warranted.
Helpful Self-talk
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 children.
Self-talk helps children coordinate their actions and thoughts and seems to be animportant tool for learning new skills and higher level thinking. Three-year-old Suzysays to herself: "This red piece goes in the round hole." Then Suzy puts the red piece intothe 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 hisreal name). His mother reported the following scene. She asks Sam to attend a familyfunction on a Sunday afternoon. Sam's regular routine is to go to the movies on Sundayafternoons. Sam tells his mother he will not go with the family. Then the mother asksSam to think it over. Sam storms off to his room and slams the door. His motheroverhears this dialogue: "You should go with your family, Sam." "But I want to go to the movies." 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 orarguing 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 abilitiesseem to internalize their self-talk earlier. As self-talk is transformed into higher levelthinking, it becomes abbreviated and the child begins to think rather than say thedirections for his or her behavior. Thus, the intellectual and speech difficulties of adultswith Down syndrome may contribute to the high prevalence of audible self-talk reportedto 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 continue to talk to themselves outloud when they are alone and confronting new or difficult tasks. Though the occurrencemay be much less frequent, the uses of the adult's self-talk seem consistent with thefindings about children. Adults talk to themselves to direct their behavior and learn newskills. Because adults are more sensitive to social context and may not want to overhear these private conversations, 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 they are alone.
Having trouble judging what is supposed to be private and what is considered "sociallyappropriate" also may contribute to the high prevalence of easily observable self-talkamong 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 isolationand the increasing difficulty of most tasks of daily living may be important explanationsfor this greater frequency of self-talk. For adults with Down syndrome, these explanationsalso make sense. Adults with Down syndrome are at greater risk for social isolation andthe 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 toprocess daily life events. This is because their speech or cognitive impairments inhibitcommunication. In fact, caregivers frequently note that the amount and intensity of theself-talk reflects the number and emotional intensity of the daily life events experiencedby 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, amother reported that her daughter "Mary" spent hours in her room talking to her "fantasyfriends" after they moved to a new neighborhood. Once Mary became more involved insocial and work activities in her new neighborhood, she did not have the time or the needto 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 forasserting 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 usefor self-talk by the adult with Down syndrome may not be that different from someonewho rarely swears but screams out a four-letter word when hitting her thumb with ahammer. Such outbursts may simply be an immediate, almost reflexive outlet for someof 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 ofself-disparagement and self-devaluation, intervention may be warranted. For example, itmay be quite harmless when "Jenny" yells "I am a dummy," once, right after her failure tobake a cake from scratch. However, if Jenny begins to tell herself over and over "I am adummy 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 totalk to himself more frequently and not just in his room at the group home. Bob seemedto lose interest in his housemates and spent more time in these conversations withhimself. Bob talked to himself, sometimes loudly and in a threatening manner, at the busstop, at the workshop, and at the group home. Bob was diagnosed as experiencing asevere form of depression. Over an extended period of time, Bob began to respond to ananti-depressant and to his participation in a counseling group.
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 onceenjoyed. 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 andharassed by a new co-worker. With the removal of the bully from his workshop, Jimgradually regained his sense of trust in the safety of the workshop. His self-talk andinterest 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 wehave observed and heard from family and caregivers suggests that self-talk is animportant coping tool and only rarely should it be considered a symptom of severe mentalillness or psychosis. A dramatic change in self-talk may indicate a mental health orsituational problem. Despite the odd or disturbing nature of the self-talk, our experienceat 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 dailylives.
Dennis McGuire, Ph.D. 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
Elaine Greenbaum, Ph.D. 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 DownSyndrome." 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 ofreferences on the uses of private speech: Diaz, R., Berk, L. Private Speech: From Social Interactionto Self-Regulation. Lawrence Erlbaum Associates, 1991. ISBN: 0805808868.
3. L. S. Vygotsky is the Russian psychologist credited with explaining how higher thought and our innersilent dialogues emerge from childhood's private speech: Vygotsky, L., in Diaz, R., Berk, L. PrivateSpeech: From Social Interaction to Self-Regulation. Lawrence Erlbaum Associates, 1991,ISBN: 0805805568.
4. McGuire, D., Chicoine, B., "Depressive Disorders in Adults with Down Syndrome. "The HabilitativeMental Healthcare Newsletter, Vol. 15, No. l, 1996, p. 1-7.

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FAHMI ISHAQ EL-URI M.B.Ch.B (Hons), MRCOG, FRCOG Tel +9626 534 2386, Mob +96279 557 1068, E-mail PERSONAL DETAILS QUALIFICATIONS FRCOG, Fellow of the Royal College of Obstetricians& Gynaecologists, London MRCOG, Member of the Royal College of Obstetricians& Gynaecologists, London MBChB (Hons) , Faculty of Medicine, Alexandria University, Egypt French Internatio

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