Selective Mutism
The essential feature of selective mutism is the
persistent failure for at least one month (but not limited to the first month
after the start of school) to speak in specific social situations where
speak-ing is expected, despite speaking in other situations (most com-monly in
the home). Children with this disorder become impaired in social and educational
settings. Selective mutism must not be diagnosed when there is a lack of
knowledge or comfort speak-ing, for example, when a child is an immigrant.
Previously referred to as elective mutism, in DSM-IV-TR the condition was renamed selective mutism, so as to be less
judg-mental. The prevalence is usually reported as 0.6 to seven per 1000, with
higher incidence in females rather than males. When subjects failing to speak
in the first few weeks of school (a DSM-IV-TR requirement) are excluded, rates
do not exceed two per1000. Onset is usually in the preschool years, but the
peak age of presentation and diagnosis is between 6 and 8 years. A high
in-cidence of insidious onset of refusal to speak with anyone except family
members is reported. The other typical picture is one of acute onset of mutism
on starting school.
Three basic theories have been proposed to explain
the etiology of selective mutism: children who are negative, oppositional and
controlling; traumatized children; and children who have severe anxiety,
chiefly social phobia. Although early psychodynamic theorists described an
enmeshed relationship between mother and child, the father being distant and
ineffectual, and a conflicted re-lationship between the parents, the only two
controlled studies of selective mutism did not find family functioning worse
compared with the families of other emotionally disturbed children (Kolvin and
Fundudis, 1981; Wilkins, 1985). Associated features include a history of
delayed speech and articulation problems, and possi-bly increased incidence of
enuresis and/or encopresis. There may be a family history of general shyness,
or of elevated levels of anxiety in the parents.
Prior to making a diagnosis of selective mutism, a comprehen-sive
evaluation should be conducted to rule out other explana-tions for mutism and
to assess important comorbid factors. For obvious reasons, the parental
interview will form the mainstay of evaluation but, as discussed below, direct
observation (and interview if it is possible) of the child can afford important
di-agnostic information important to obtain information of the nature of the
onset (insidious or sudden), any uncharacteristic features (i.e., not talking
to family members, abrupt cessation of speech in one setting, absence of
communication in all set-tings) suggestive of other neurological or psychiatric
disorders (e.g., pervasive developmental disorders, acquired aphasias), and any
history of neurological insult/injury, developmental delays, or atypical
language and/or speech. The assessment should also include the degree to which
nonverbal communication or non-face-to-face communication is possible, the
presence of anxiety symptoms in areas other than speaking, social and
behavioral inhibition, medical history including ear infections and hearing
deficiencies. Parents will be able to give information on where and to whom the
child will speak, the child’s speech and lan-guage complexity at home,
articulation problems, use of non-verbal communication (e.g., gestures), any
history of speech and language delays, and the possible importance of
bilingualism (where primary language is not English). It can be useful to have
the parents provide an audiotape of the child speaking at home. The child evaluation
can assess the presence of anxiety and so-cial inhibition (willingness to
communication through gesture or drawing). Physical examination of oral sensory
and motor ability may provide evidence of neurological problems (i.e.,
drooling, asymmetry, orofacial weakness, abnormal gag reflex, impaired sucking
or swallowing). Specialist audiometry (pure tone and speech stimuli as well as
tympanometry and acoustic reflex test-ing) may provide evidence of hearing
and/or middle ear prob-lems that can have a significant effect on speech and
language development. Cognitive abilities may be difficult to assess, but the
performance section of the WISC-R or Raven’s Progressive Matrices as well as
the Peabody Picture Vocabulary Test may be useful in the nonverbal child.
Treatment
has long been regarded as difficult and the prognosis poor. Approaches have
included behavioral therapy, family ther-apy, speech therapy and, more
recently, pharmacological agents. Unfortunately most published studies are
single case reports, with very few controlled studies.
Behavioral
treatment focuses on mutism as a means of get-ting attention and/or escaping
from anxiety. A controlled study (Calhoun and Koenig, 1973) of eight subjects
with random as-signment to treatment (teacher and peer reinforcement of ver-bal
behavior) or control showed significant increases in mean number of
vocalizations after 5 weeks of treatment. These gains were not, however,
maintained at 12-month follow-up. Other techniques have included graded exposure,
shaping and mod-eling. The goal of a treatment program should be to decrease
the anxiety associated with speaking whilst encouraging the child to interact
verbally.
Regarding
pharmacotherapy, the use of SSRI medication in cases of selective mutism with
associated anxiety (principally social phobia) has promise. An open trial of 21
children using a mean dose of 28.1 mg/day of fluoextine showed improvement in
76% of cases (Dummit et al., 1996). A
placebo-controlled double-blind study showed mixed results, though both groups
remained highly symptomatic. More chronic (.14 weeks) treatment was
recommended (Black and Uhde, 1994).
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