The Boundaries of Forensic Psychiatric Expertise in Hearing Impairment: A Case Series

Abstract

(1) Background: Communication barriers may complicate forensic psychiatric assessment of deaf or hard-of-hearing individuals. (2) Methods: This retrospective descriptive case series reviewed 450 unique adults with institutional and forensic psychiatric records at a high-security hospital in Iasi County, Romania (2015–2025). Six individuals (N = 6; 6/450, 1.33%) met the record-based criteria for profound bilateral hearing loss with severe speech or spoken-language impairment. No examination was performed specifically for the study. (3) Results: Four of six individuals had documented congenital or prelingual profound bilateral hearing loss, and two had profound bilateral coexisting conductive and sensorineural hearing-loss components. Four had no formal schooling, and two had partial compulsory schooling; all six lacked documented standardized sign-language competence. Initial records did not document effective communication access or audiological confirmation, and psychiatric formulations were inconclusive or changed over time. Forensic discernment was recorded as absent in 5/6 individuals (83.3%). (4) Conclusions: Communication limitations may have contributed to assessment uncertainty alongside educational, cognitive, psychiatric, and social factors. The series does not confirm misdiagnosis, causation, or population prevalence.

1. Introduction

Evidence on forensic psychiatric assessment of deaf or hard-of-hearing adults in high-security settings remains limited. This case series describes documented communication access, diagnostic pathways, and legal outcomes in one Romanian institution without assuming that prior diagnoses or judicial decisions were incorrect.

Personality, symptom, and psychological questionnaires are not inherently invalid for deaf or hard-of-hearing people. Their interpretability depends on functional language, literacy, cultural-linguistic adaptation, and validation of the administration mode. Signed-language questionnaires and recent adapted depression inventories demonstrate that a written instrument cannot simply be assumed equivalent to a culturally and linguistically validated signed version [1,2,3,4,5]. None of the six records documented an instrument validated for the individual’s actual communication abilities.

Hearing loss may be congenital or acquired and may occur before or after spoken-language development. For forensic assessment, onset and access to an established language are especially relevant: prelingual loss may affect language acquisition when accessible communication is delayed, whereas postlingual loss affects an already developed linguistic system [6,7,8].

Language-deprivation research provides a framework for considering limited early access to an accessible natural language [6,7,8]. Such history may be relevant to language fluency, cognitive testing, and behavior, but it was not measured systematically in this study and is not treated as a demonstrated cause of the recorded outcomes.

Auditory rehabilitation depends on hearing-loss type and severity, residual hearing, communication history, and individual goals. Hearing aids may be appropriate when residual hearing is aidable, whereas limited benefit from amplification in severe-to-profound sensorineural loss may prompt cochlear-implant evaluation [9,10]. Psychiatric illness requires coordinated assessment but is not, by itself, an automatic contraindication [10].

For the present forensic question, the relevant clinical descriptors were onset, bilaterality, severity, type of hearing loss, residual hearing, use of hearing devices, language competence, and education. A detailed catalogue of medical etiologies was omitted because causes unrelated to eligibility or differential interpretation did not inform the case-series objectives.

Hearing loss may be associated with communication effort, social isolation, and depression [9,11,12]. In a forensic setting, however, assessment must integrate communication access with psychiatric symptoms, cognition, collateral information, and the jurisdiction’s legal criteria [13,14,15].

The descriptive research question was whether the records showed diagnostic uncertainty when auditory access, functional language, and effective communication support were limited. The study did not test whether communication barriers caused a diagnosis or judicial outcome.

Accordingly, the study characterizes the six eligible records and identifies assessment considerations without testing a causal hypothesis or re-adjudicating historical psychiatric or legal conclusions.

The study aimed to

• identify the observed institutional proportion of unique individuals meeting the record-based case criteria;
• describe communication modalities and interpreter access during forensic evaluations;
• describe the types and stability of psychiatric formulations recorded when functional communication access was limited;
• examine forensic discernment outcomes and legal measures applied;
• identify diagnostic and procedural difficulties observed in this six-case series without attributing them to a systemic failure.

2. Materials and Methods

For this study, ‘profound hearing loss’ referred to the final ear, nose, and throat (ENT) or audiological classification documented in the clinical file. Where numerical thresholds were available, profound loss was interpreted consistently with the World Health Organization grading framework (four-frequency pure-tone average of at least 80 dB hearing level in the better ear) [16]. ‘Bilateral’ meant that both ears were affected. ‘Coexisting conductive and sensorineural hearing-loss components’ meant a record-based diagnosis indicating both sensorineural and conductive components, conventionally reflected by elevated air- and bone-conduction thresholds with an air–bone gap. ‘Severe speech or spoken-language impairment’ meant that the files documented absent or minimal intelligible spoken communication that prevented an ordinary spoken interview. ‘Congenital or prelingual’ indicated onset at birth or before spoken-language acquisition, based on developmental history in the records. Because complete audiograms and developmental histories were not consistently preserved, classifications were not independently recalculated by the research team.

The clinical evaluation of hearing loss may draw on several complementary procedures, including ENT examination, behavioral audiometry, impedance measurements, and objective audiological testing [17,18]. Review of the six case files showed that routine care consistently included an ENT examination, audiometry, reported as either pure-tone or tonal audiometry, and cranio-cerebral computed tomography (CT). However, the records did not provide consistent information on the equipment used, calibration, transducer type, masking procedures, frequency-specific thresholds, reliability of behavioral responses, speech audiometry, tympanometry, otoacoustic emissions, or auditory brainstem responses.

This was a retrospective observational case series nested within a complete institutional source cohort. The objectives were descriptive: to identify eligible records and characterize communication, diagnostic, audiological, forensic, and legal pathways. The study did not estimate population prevalence, test causal hypotheses, or perform inferential comparisons.

The source cohort comprised 450 unique adult individuals who were admitted to, or remained under a security measure in, the Padureni-Grajduri Psychiatry and Safety Measures Hospital and had relevant forensic psychiatric documentation during 1 January 2015–31 December 2025. The individual, not the admission, commission meeting, or evaluation episode, was the unit of analysis. Repeated admissions and repeated six- or twelve-month evaluations were linked longitudinally to the same individual and were not counted as additional denominator observations. An individual whose hospitalization began before 2015 was eligible if the person remained hospitalized and had relevant records during the study window; the documented duration of hospitalization could therefore exceed the ten-year record-review window.

Eligibility required age over 18 years and a file diagnosis of profound bilateral hearing loss together with severe speech or spoken-language impairment. The criterion was not restricted to coexisting conductive and sensorineural hearing-loss components: the final routine-care documentation classified four individuals as having congenital or prelingual profound bilateral hearing loss with limited spoken-language development and two as having profound bilateral coexisting conductive and sensorineural hearing-loss components with severe speech impairment. Exclusion criteria were documented hearing loss secondary to cranio-cerebral trauma or another clearly acquired pathology, reversible ENT conditions affecting hearing, and death before the database lock. These are record-based categories and not diagnoses independently validated for this research.

The combined auditory-and-spoken-communication criterion reflected the study question concerning forensic evaluability when both auditory access and spoken communication were severely restricted. The source database did not contain consistently coded, audiologically confirmed variables for hearing loss alone, coexisting conductive and sensorineural hearing-loss components alone, or isolated speech impairment in all 450 unique individuals. Those groups could not be validly enumerated or compared, and their absence from the case series must not be interpreted as absence from the institution.

Ethics approvals from the Padureni-Grajduri Psychiatry and Safety Measures Hospital (No. 2660/20 March 2025) and the Institute of Legal Medicine of Iasi (No. 36836/20 March 2025) authorized the retrospective record-review framework [19,20]. The source database was locked after 31 December 2025, and record extraction and analysis used completed clinical documentation. The Data Protection Officer statement (No. 1213/29 May 2026) was a subsequent GDPR compliance confirmation during analysis and manuscript preparation, not a second ethics approval or authorization for a prospective intervention.

Direct identifiers were not extracted. Nevertheless, the research team recognized that a rare forensic population remains vulnerable to deductive disclosure through combinations of age, offense, residence, communication profile, and hospitalization duration [21]. Accordingly, results are reported in summary form; age and duration were grouped, rare offense labels and individual combinations were suppressed, and no case-level table is provided. The working dataset was kept within the authorized institutional environment, and missing identifiers alone were not treated as sufficient proof of anonymity.

N = 6 records met the inclusion and exclusion criteria. The ENT examinations, audiometry, and cranio-cerebral CT examinations described in the files had been performed as part of routine clinical care before research extraction and were not commissioned prospectively for this study. The same ENT specialist documented the ENT reassessment and final hearing classification; CT findings were taken from routine radiology reports. The files did not consistently identify the audiology operator or radiologist, and no independent audiological or radiological re-reading was performed. No research-specific examination, intervention, or additional participant contact occurred.

Among 450 unique individuals in the institutional source cohort, six met the strict record-based criteria (observed institutional proportion 6/450, 1.33%). This is a case yield from retrospective screening, not a prevalence estimate or an epidemiological footprint. Under-ascertainment is possible because undiagnosed or incompletely recorded hearing loss would not have been captured. N = 6 precludes reliable subgroup comparison, inferential analysis, and broad generalization.

2.1. Analytical Framework and Variables of Interest

Records were screened by T.I., and eligibility and extracted information for the six included records were independently reviewed by C.R.; ambiguous clinical or forensic entries were discussed with S.M.D. and resolved by consensus. Data were extracted using a predefined form covering demographics, education, hearing classification, communication modality, interpreter involvement, historical psychiatric formulations, forensic discernment, legal measures, and hospitalization. Missing information was coded as ‘not documented’ and was not interpreted as absence; ambiguous wording was retained as uncertain and was not recoded into a definitive category.

Operationally, ‘functional language access’ meant documented access to a language or communication system sufficient for reciprocal understanding during assessment. ‘Standardized sign-language competence’ required explicit documentation of education in or functional use of a recognized sign language; gestures or idiosyncratic home signs did not meet this definition. ‘Communication success’ meant that the record documented sufficiently reliable two-way communication to complete the intended interview without unresolved access concerns. ‘Family support’ required documented ongoing contact or practical involvement. ‘Diagnostic inconsistency’ meant a change between named diagnoses or repeated inconclusive/provisional formulations across reports. A ‘definitive psychiatric diagnosis’ required an explicitly final, non-provisional commission conclusion. Historical intellectual-disability and psychiatric diagnoses were transcribed as file diagnoses and were not independently validated.

Historical diagnostic terminology was generally compatible with the International Classification of Diseases, Tenth Revision (ICD-10), but the files did not consistently preserve item-level diagnostic criteria. Forensic reports were issued by multidisciplinary commissions; exact membership and qualifications at every historical evaluation were not uniformly available. The records did not document a psychological or cognitive instrument validated for the individuals’ language and literacy. The final diagnostic status used in this study was therefore the most recent explicit commission formulation in the file, categorized as definitive, provisional, changed, or inconclusive, not an independent reference-standard diagnosis.

For international readers, ‘forensic discernment’ is used here as the record-based Romanian medico-legal determination of whether, at the time of the alleged act, the individual had the capacity to understand its nature and consequences and to control conduct; it is not presented as a psychiatric diagnosis. It was transcribed as preserved or absent from commission reports. Article 109 of the Romanian Criminal Code concerns compulsory medical treatment, whereas Article 110 concerns compulsory medical hospitalization [22]. Commission recommendations and court-ordered measures were recorded separately. A difference between them was described without being classified as legal or clinical error because the full judicial reasoning was not available.

The extracted variables were summarized descriptively according to the structure and completeness of the available records.

2.2. Statistical Analysis

Analysis was limited to counts and percentages. Given N = 6 and the absence of a valid comparison group, no confidence intervals, hypothesis tests, or inferential models were calculated; accordingly, no statistical software is reported.

3. Results

The results describe N = 6 unique male individuals identified among N = 450 unique persons in the institutional source cohort (observed proportion 1.33%). To reduce deductive-disclosure risk, ages are reported as a band (35–54 years), and rural and urban backgrounds are reported without publishing potentially identifying individual combinations. Four individuals had no formal schooling, and two had partial compulsory schooling. None had documented standardized sign-language competence or hearing-aid use.

Medical, psychiatric, familial, and behavioral information was extracted from existing records rather than new interviews. Table 1 summarizes aggregated clinical, educational, communication, and forensic characteristics; historical diagnoses are labeled as such because their validity could not be independently established.

Table 1. Aggregated characteristics of the six-case series (N = 6).

Characteristic	Observed Finding
Participant, educational, and communication profile
Sex	Male: 6/6 (100%)
Age	35–54-year band: 6/6 (100%); exact ages suppressed
Area of origin	Rural and urban backgrounds represented; exact counts suppressed
Formal education	None: 4/6 (66.7%); partial compulsory schooling: 2/6 (33.3%)
Standardized sign-language competence	Not documented: 6/6 (100%)
Family support	Documented as absent: 6/6 (100%)
Hearing-aid use	Not documented: 6/6 (100%)
Hearing classification and historical file diagnoses
Congenital/prelingual profound bilateral hearing loss with limited spoken-language development	4/6 (66.7%)
Profound bilateral coexisting conductive and sensorineural hearing-loss components with severe speech impairment	2/6 (33.3%)
Historical file diagnosis: moderate intellectual disability	6/6 (100%)
Historical file diagnosis: delusional disorder	1/6 (16.7%)
Historical file diagnosis: organic affective disorder	1/6 (16.7%)
Definitive psychiatric diagnosis after staged assessment	Not established: 6/6 (100%)
Forensic assessment characteristics
Certified interpreter at initial assessment	Not documented: 6/6 (100%)
Conventional interpreter available at later staged assessment	Documented: 6/6 (100%)
Effective functional communication during staged assessment	Not established: 6/6 (100%)
Prior criminal record	Present: 3/6 (50.0%); absent: 3/6 (50.0%)
Forensic discernment at time of alleged act	Preserved: 1/6 (16.7%); absent: 5/6 (83.3%)

All values refer to N = 6 unique individuals and are reported as n/N (%) where applicable. Historical file diagnoses may overlap and are not independently validated final diagnoses. Age, residence, and rare combinations were grouped or suppressed to reduce deductive-disclosure risk.

The remaining 444 individuals were not used as a comparator group because equivalent audiological, language, communication, diagnostic, and legal variables were not extracted under the same operational definitions. No rate comparison or inferential test was performed. The value 6/450 is only the observed case yield within the institutional source cohort.

3.1. Communication Barriers and Assessment Limitations

Initial forensic reports did not document a certified interpreter, audiological confirmation, or a communication method shown to provide reliable reciprocal access. Later reports documented conventional interpreter availability, but all six individuals lacked documented competence in the interpreter’s standardized sign language. Interpreter presence was therefore distinguished from effective communication access: the latter remained uncertain because gestures, home signs, limited speech, and nonverbal behavior did not establish a shared language.

3.2. Psychiatric Diagnoses and Assessment Outcomes

At initial assessment, the four individuals with congenital or prelingual profound bilateral hearing loss and limited spoken-language development had historical file diagnoses of moderate intellectual disability, sometimes further described as disharmonic or accompanied by behavioral disturbance. These are reported as historical formulations, not as independently confirmed diagnoses.

The records additionally contained one historical diagnosis of delusional disorder and one of organic affective disorder.

The two individuals with profound bilateral coexisting conductive and sensorineural hearing-loss components and severe speech impairment also had historical file diagnoses of moderate intellectual disability with behavioral disturbance. Diagnostic categories could therefore overlap.

At later staged evaluations, a conventional interpreter was documented as available. Because none of the six individuals had acquired the relevant standardized sign language, interpreter availability did not ensure functional language access. The reports remained provisional, changing, or inconclusive, and the files did not document use of validated language-adapted psychological or nonverbal cognitive instruments.

3.3. Complementary Examinations

Routine-care records documented ENT examination, audiometry, and cranio-cerebral CT for all six individuals. Final documentation classified four as having congenital or prelingual profound bilateral hearing loss with limited spoken-language development and two as having profound bilateral coexisting conductive and sensorineural hearing-loss components with severe speech impairment. No structural neuraxial abnormality detectable on the available CT examinations was reported; normal CT findings do not exclude microscopic, functional, genetic, metabolic, or other neurological causes.

3.4. Educational, Social, and Familial Context

Four individuals had no formal schooling, and two had partial compulsory schooling. None had documented sign-language instruction, hearing-aid use, or stable employment before institutionalization. Employment disadvantage is reported in other deaf populations [23], but no causal inference is made for this series.

The files described absent family support and substantial social vulnerability. Both rural and urban backgrounds were represented. Exact age-residence-offense combinations are not reported because, in a six-person legally sensitive cohort, such combinations could facilitate re-identification.

3.5. Criminal Offenses and Recidivism

Table 2 summarizes the forensic and legal characteristics of the six cases while limiting granular combinations that could increase the risk of deductive disclosure.

Table 2. Forensic and legal outcomes in the six-case series.

Variable	Finding in the Six-Case Series (N = 6)
Alleged offense groupings	Sexual, property, interpersonal-violence, domestic-violence, and public-official-related allegations were represented; rare labels and individual combinations were suppressed
Prior criminal record	Present: 3/6 (50.0%); absent: 3/6 (50.0%)
Forensic discernment at time of alleged act	Preserved: 1/6 (16.7%); absent: 5/6 (83.3%)
Forensic commission recommendation	Article 109: 1/6 (16.7%); Article 110: 5/6 (83.3%)
Court-ordered security measure	Article 110: 6/6 (100%)
Judicial rationale	Complete reasoned judgments were not available; the difference from the commission recommendation is descriptive and is not classified as an error
Hospitalization duration	≤5 years: 4/6 (66.7%); 6–10 years: 1/6 (16.7%); >10 years: 1/6 (16.7%)

Article 109 of the Romanian Criminal Code concerns compulsory medical treatment; Article 110 concerns compulsory medical hospitalization [22]. Article 109 is a security measure, not an offense. ‘Forensic discernment’ refers to the record-based capacity to understand the nature and consequences of the alleged act and to control conduct. Offense details were aggregated, and exact individual combinations were suppressed, to reduce deductive-disclosure risk.

The records were grouped into broad allegation categories rather than publishing rare offense labels or individual combinations. A historically ambiguous file notation referring to Article 109 was not treated as an offense in the revised analysis because Article 109 defines a security measure.

Prior criminal records were documented for three of six individuals; offense-specific histories were suppressed to reduce re-identification risk.

Forensic discernment was recorded as preserved in one case and absent in five. Because the offense variables were neither mutually exclusive nor consistently countable, no offense category is presented as an estimated rate or ranked prevalence.

3.6. Legal Measures and Hospitalization

The forensic commissions recommended Article 109 in one case and Article 110 in five, whereas the courts ordered Article 110 in all six. The complete judicial reasoning underlying the court orders was not present in the reviewed dataset. The observed difference is therefore reported descriptively and is not interpreted as an error by either the commission or the court.

To reduce disclosure risk, hospitalization duration is reported in grouped form: four individuals had been hospitalized for five years or less, one for six to ten years, and one for more than ten years. A duration exceeding the 2015–2025 review window reflects hospitalization that began before 2015 and continued into the study period.

4. Discussion

4.1. Interpretation of Descriptive Findings

Restricted communication access co-occurred with inconclusive or changing formulations, but it was only one of several possible contributors. Minimal schooling may affect literacy and familiarity with testing; socioeconomic adversity and absent family support may reduce access to collateral history and rehabilitation; historical intellectual-disability or psychiatric diagnoses may reflect genuine morbidity, prior misclassification, or both. Because these domains were not assessed with standardized measures, their relative contributions cannot be quantified.

No file documented hearing-aid use or previous cochlear-implant candidacy assessment. Audiological rehabilitation may include fitted hearing aids or cochlear-implant evaluation according to clinical indications [9,10]. The retrospective data cannot show whether a hearing device would have changed psychiatric assessment or legal outcomes.

The co-occurrence of absent effective communication access and absent recorded forensic discernment in five cases is compatible with communication difficulties having contributed to uncertainty; it does not show that they caused incorrect forensic judgments. Psychiatric symptoms, cognition, education, social context, and the quality of collateral evidence remain alternative or interacting explanations.

Criminal responsibility was transcribed from the records rather than re-determined by this study. It depends on jurisdiction-specific legal criteria and an integrated evaluation of mental disorder, cognitive and volitional capacities at the time of the alleged act, temporal relationship to the act, reliability of the examination, and collateral information [13,14,15,22,24]. Communication access affects the reliability of that evaluation but cannot, by itself, establish or exclude criminal responsibility.

The observations are broadly consistent with language-deprivation frameworks [6,7,8] but do not confirm them. Early language exposure, current language competence, nonverbal cognition, psychiatric symptoms, and socioeconomic conditions were not measured systematically; the findings are therefore hypothesis-generating.

4.2. Broader Theoretical and Forensic Context

Alternative assessment approaches described in the literature include direct examination by sign-language-fluent clinicians, certified or specialist interpreters, formal assessment of actual language competence, culturally adapted signed-language symptom scales, nonverbal cognitive instruments, adapted interviews, collateral records, and multidisciplinary longitudinal review [1,2,3,4,5,24,25,26,27,28]. No single method removes uncertainty, and selection must be matched to the person’s actual language and literacy.

Reliance on behavior and incomplete collateral records may also increase vulnerability to interpretive bias [29,30,31]. Evaluator bias was not measured in this study and is considered only as a possible mechanism.

Recent systematic and empirical evidence supports linguistic and cultural adaptation of clinical tools [3,4,5]. However, a validated signed questionnaire is applicable only when the individual understands that sign language. It cannot be assumed valid for a person who never acquired it. In that situation, nonverbal methods, communication facilitation, and collateral information become particularly important [24,25,26,27,28].

4.3. Implications for Forensic Practice and Policy

Potential components of a more structured forensic assessment include qualified communication support, formal language assessment, adapted psychological or nonverbal tools, collateral information, and coordinated psychiatric, audiological, psychological, and legal review [1,2,3,4,5,24,25,26,27,28]. These are assessment options described in the literature, not effects demonstrated by this case series.

Across the six records, communication limitations, incomplete audiological documentation, limited education, social adversity, and changing psychiatric formulations occurred together. The design cannot separate their effects on diagnosis, discernment, or hospitalization.

Documentation quality is another relevant domain. The electronic-record and health-system communication sources [32] support traceability and continuity of information only and are not used to infer causation in these cases.

4.4. Priorities for Future Research

Future research should test whether formal language assessment and adapted communication change psychiatric formulations or discernment determinations, and which nonverbal cognitive tools are valid for adults with minimal formal language. These questions would be better addressed through prospective multicenter studies with standardized communication, audiological, cognitive, and psychiatric measures [3,4,5,24].

4.5. Limitations

Several limitations should be acknowledged. This was a single-center, retrospective case series with only six eligible individuals, all male, from a legally sensitive institutional population. The small sample limits precision, subgroup analysis, generalizability, and any prevalence inference. Case ascertainment depended on incomplete routine records, so unrecognized hearing loss and misclassification are possible. Numerical audiograms, test reliability indicators, objective audiological tests, standardized language measures, adapted cognitive instruments, commission composition, and item-level diagnostic criteria were not consistently available. Historical diagnoses were not verified against an independent reference standard. The remaining 444 individuals were not a valid comparison group. Selection and survivorship bias are possible, especially for long-stay patients. Deductive disclosure constrained reporting detail. Finally, the design cannot determine whether communication support, hearing rehabilitation, psychiatric symptoms, cognition, education, or social adversity caused diagnostic uncertainty, discernment decisions, court orders, or hospitalization duration, nor whether adapted support would have changed those outcomes.

4.6. Practice and Policy Considerations

The following considerations listed in Table 3, combine observations from N = 6 with the cited literature. They are not treatment recommendations, effectiveness claims, or legal directives and require prospective evaluation.

Table 3. Summary of implications.

Clinical and Audiological Considerations	Consider ENT and audiological assessment using behavioral and objective methods appropriate to the individual’s communication abilities; use cranio-cerebral CT or other imaging only when clinically indicated. Assess candidacy for appropriately fitted hearing aids and, when amplification benefit is limited in severe-to-profound sensorineural hearing loss, consider cochlear-implant evaluation [9,10]. Document test method, thresholds, response reliability, and follow-up plan.
Communication and Language Considerations	Formally assess actual language and communication abilities before selecting a communication method [24,25,26,27,28]. Do not equate interpreter presence with effective access; a conventional sign-language interpreter may be ineffective when the person has not acquired that language. Consider, as appropriate and available, specialist or deaf interpreters, communication facilitators, visual supports, augmentative and alternative communication, gestures, and simplified language.
Psychiatric and Psychological Considerations	Use adapted or nonverbal instruments only when their validity is appropriate to the individual’s language, literacy, and cultural background [1,2]. Combine accessible interviewing with behavioral observation, collateral information, and longitudinal records. Document diagnostic uncertainty and distinguish language deprivation, cognitive limitation, psychiatric symptoms, and social adversity where possible.
Educational and Psycho-pedagogical Considerations	Consider individualized literacy, language, and educational support based on assessed needs [6,7,8]. Do not assume that late sign-language instruction fully compensates for early lack of accessible language.
Social and Rehabilitation Considerations	Develop individualized rehabilitation plans addressing education, communication access, social vulnerability, and family or community support. Consider supported vocational and community-integration opportunities compatible with communication abilities. Coordinate discharge planning with social and legal services when clinically and legally feasible.
Forensic and Legal Considerations	Use formal interdisciplinary procedures for deaf or hard-of-hearing defendants [24,25,26,27,28]. Use caution in discernment determinations when language, cognition, psychiatric symptoms, and social adversity cannot be reliably distinguished [7,29,30,31]. Document separately the commission recommendation, the court-ordered measure, and the available legal rationale under Articles 109 and 110 [22].

ENT = ear, nose, and throat; CT = computed tomography. Article 109 concerns compulsory medical treatment, and Article 110 compulsory medical hospitalization under the Romanian Criminal Code [22].

5. Conclusions

This single-center retrospective series describes six individuals with profound bilateral hearing loss and severe spoken-communication impairment whose records showed restricted communication access and changing or inconclusive psychiatric formulations. The observations indicate diagnostic uncertainty and a potential risk of misclassification; they do not confirm misdiagnosis, estimate prevalence, or establish that communication barriers caused forensic or legal outcomes.

The principal practical implication is to assess actual language and communication abilities, not interpreter availability alone, and to integrate audiological, psychiatric, psychological, collateral, and legal information. Prospective multicenter studies using standardized language, communication, nonverbal cognitive, audiological, and psychiatric measures are needed to determine whether adapted support changes diagnoses or discernment determinations.