ABSTRACT
A real difficulty is that any cause of distress can be accompanied by any behaviour, sign or expression. Psychiatric conditions such as severe depression or psychosis will hinder or prevent communication and any acute confusional state will also hinder communication. Patients have difficulty communicating in different contexts such as coma, cancer, and brain damage. The most common cause in children is a brain infection (encephalopathy) and in adults it is dementia. Shortage of oxygen at birth can cause cerebral palsy which in some children (but not all) causes difficulties in speech or understanding. Trauma or strokes can do the same. There are many ways that people could express distress: sounds; facial expression; easing the discomfort; distraction; and posture. In people using alternative communication, the language is made up mainly of behaviours, signs and verbal expressions. The difficulty is knowing what these behaviours, signs and expressions mean. They can only be understood with close observation.
